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Aboriginal health-benefit claims under review

A number of pharmacies have come under scrutiny from the company that handles claims made to the aboriginal health-benefits plan, newly released documents show.

Confidential audits offer a rare glimpse at some of the billings that raised questions in the minds of the claims administrator.

Among them are claims with missing or mismatched paperwork, unauthorized prescriptions and refills and excessively high dispensing fees.

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The Canadian Press obtained hundreds of pages of audits under the Access to Information Act. The audits come from Mississauga, Ont.-based Express Scripts Canada, which administers claims for dental, medical supplies and equipment and pharmacy benefits on behalf of the Non-Insured Health Benefits program for first nations people and Inuit.

In some cases, honest mistakes or simple oversights, such as forgetting to submit paperwork, appear to explain the billing issues. Other times, pharmacies were asked to repay thousands of dollars for improper billings.

An Express Scripts Canada audit alleges one Yukon pharmacy billed for items not covered by the NIHB program and split prescriptions to charge additional dispensing fees. The drug store was asked to pay back more than $25,000.

Another audit alleges a New Brunswick pharmacy billed the program for doses of methadone it never actually dispensed to patients.

"It could be a large variety of things," said Sandra Bruce, the NIHB program's director-general. "Maybe the pharmacist pressed the wrong button, and when you do your audit checks right, it goes, 'Hang on, that button doesn't match.'

Only a handful of cases have been turned over to law-enforcement authorities, Ms. Bruce said.

That's not counting cases where the federal government has gone to court to recoup money from service providers – sometimes, millions of dollars.

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Ottawa is suing a Manitoba pharmacist and his former drug store for $3.1-million over allegations they fleeced the aboriginal health-benefits plan.

Another Nova Scotia pharmacist and his numbered company face a $1.36-million lawsuit over allegedly "fraudulent" claims.

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