How do you make a ton of money selling a potent drug intended only for late-stage cancer patients? Defrauding insurance companies may have been the solution for one company, authorities say.
Elizabeth Gurrieri, a former Insys Therapeutics manager, was charged last week with conspiring to defraud insurers into covering a fentanyl spray intended for cancer patients called Subsys. The criminal complaint was filed in a federal court in Boston, and Gurrieri was arrested on Thursday, according to Reuters.
Fifty times stronger than heroin, fentanyl is a potent opioid responsible for making the heroin epidemic even deadlier and for killing pop idol Prince in the form of an illicit pill. Fusion reported on its growing role in America’s rising drug-addiction problem, as well as on Insys’ business practices, in an hourlong documentary, Death by Fentanyl, and an online investigative package last January.
Gurrieri ran an Insys team responsible for getting insurance companies to authorize payments for Subsys. For its documentary, Fusion spoke with one of Gurrieri’s subordinates, whistleblower Patty Nixon, who said Gurrieri instructed her to tell insurance companies that patients had cancer when they did not. In Nixon’s estimate, 90 percent of patients whose cases were referred to her unit did not have cancer.
“It’s real simple: It’s only FDA approved for cancer patients with breakthrough cancer pain,” Nixon told Fusion. “If you don’t have cancer, and breakthrough cancer pain, no insurance company is going to pay for this medication.”
According to the criminal complaint, Gurrieri and other employees knew that Insys would lose substantial profits if insurers only authorized payment for Subsys when it was prescribed according to its label. In order to get around this, the complaint says, employees like Nixon were directed by Gurrieri to answer using a script, sometimes called “the spiel,” to mislead insurers. “The spiel” deliberately omitted the word “cancer,” according to the complaint.
“She created this,” Nixon told Fusion. “She was very proud of it. She was very, very proud.”
One tactic involved using the phrase “uh-huh” instead of “yes” when insurance providers asked if the patient had cancer, Nixon said.
“I could have said ‘no.’ And then I got denied. And then I don’t get it approved. And then I’m not hitting my numbers. And I’m going to be reprimanded,” Nixon said.
The motivation for using “the spiel” was clear, said Nixon: “10 percent of the patients — the charts that came over — or less were cancer patients. That’s not a lot of money. Nobody’s going to get rich off of that. But you have this whole other world of everybody. That ‘my back hurts’ money. ‘My knee hurts’ money.”