What You Need to Know About Preventing Fraud, Waste & Abuse

Know everything you need to know about protecting your organization from pharmacy benefit fraud, waste and abuse? Chances are you don’t – that’s why we’ve got you covered.

During a recent World Congress webinar, Carrie Aiken, CHC, Vice President of Corporate Compliance and Chief Compliance Officer at Navitus, discussed what plan sponsors should know about pharmacy benefit fraud, waste and abuse (FWA).

Don’t worry if you missed it; we’ve gathered all the important details, starting with a brief recap of the information presented, which included:

The pharmacy benefit manager’s (PBMs) role in monitoring claims, providing education or applying controls to prevent financial loss, improving member safety and support claims integrity.

Resources and techniques your PBM should be leveraging to identify suspicious patterns and investigate the underlying source.

The importance of collaborating with PBMs to preserve the integrity of the pharmacy benefit, avoid financial losses and protect plan members from harm.

Now, let’s dive deeper into the webinar specifics.

The High Cost of Fraud

The Academy of Managed Care Pharmacy estimates that 3% to 10% of all healthcare expenditures are attributable to fraud—and that includes pharmacy claims. But steps can be taken by organizations to minimize their risk by looking to their PBM to help identify fraud and support them with strategies to prevent it.

Monitoring Claims

PBMs use resources like pharmacy audits and data mining to monitor claims for FWA. Pharmacy audits look for things like drug attributes as well as packaging, dispensing, dosing and units. Data mining can deliver incredibly meaningful findings and outcomes. It enables large data capture that lets PBMs scrutinize data for any deviations and challenging behaviors to explore further. It also allows for continuous claim selection, so PBMs can keep an eye on specific patterns over time.

Investigating Claims

PBMs also investigate pharmacy and prescriber claims and member behaviors, including whether they may be pharmacy shopping or attempting to get early refills. They also review social media and other online activity, where there may be clues or details about how their fraud is being perpetrated. Enforcement websites run by the Department of Justice and other law enforcement organizations as well as ranking sites like HealthGrades can also help PBMs in investigating individuals, practitioners and pharmacies for fraud as well as other issues like safety concerns.

FWA Trends

From foot baths to formulary abuse to COVID treatments, PBMs should be actively investigating FWA trends. Through relationships with industry associations, fraud partnerships and pharmaceutical manufacturers, PBMs can receive alerts on fraudulent activities or trends, enabling them to evaluate claims for impact.

collaboration & outreach

In the webinar, Aiken emphasizes that “pharmacy benefits managers shouldn’t be a handoff—It should be a handshake.” That means collaborating with PBMs throughout the FWA process including shared concerns like medical necessity, case management, recoveries and avoidance as well as referral escalation.

PBMs also should be your partner for FWA education and outreach, from promoting PBM hotlines for members to providing trend information health plans can share with their customer service team and spotlight in your organization’s publications as well. Remember: The goal is to educate and cross-pollinate. What PBMs can contribute to your organization to help reinforce FWA prevention activities and end the cycle.

Here are a few best practices to keep in mind as you move forward with your own FWA prevention efforts:

Ask questions about your PBM’s activities on fraud, waste and abuse.

Understand the opportunities in your pharmacy claims data.

Be clear on what actions and corrections you need to take.

Ensure outreach in education is meaningful and continuous.

Want to delve even further into the information presented in this webinar? Review it on demand and/or share it with your team members.

Have more questions? Email us at [email protected] or contact your account team today to learn more!