Fraud, Waste, and Abuse

December 26, 2024

What is Fraud, Waste, and Abuse?

Fraud is when someone knowingly uses false information or statements to obtain prescription drugs or payment for prescription drugs when the person is not entitled to the drugs or payment.

Some examples of fraud are:

  • A pharmacy submitting claims for medications that the patient never received;
  • A pharmacy sending creams or supplies to a member who does not need them and has asked the pharmacy to stop sending them;
  • A patient or other person forging or altering a prescription;
  • A person obtaining prescriptions for drugs in order to sell them;
  • A claim for weight loss drugs falsely submitted with a diagnosis of diabetes so it will pay under the pharmacy benefit;
  • A physician writing a prescription for drugs because the physician receives a kickback payment; or
  • A member selling their medical ID card or prescription to someone.

Steps you can take to prevent fraud:

  • Protect your member ID card;
  • Do not give your personal information to someone you do not know;
  • Do not agree to offers for free prescriptions, supplies, or gifts for your personal information;
  • Report prescriptions that you did not order or come from a pharmacy you do not know;
  • Safely dispose of your unused or expired medication. See the FDA site for Drug Disposal.

Waste and Abuse includes actions that may result in unnecessary costs such as requesting payment or filling prescriptions for drugs when there is not entitlement. Some examples include:

  • Using another person’s insurance coverage or card;
  • Letting someone use your insurance card because they don’t have insurance;
  • A pharmacy billing for brand medication, when it dispensed a generic medication;
  • A person falsely stating drugs were lost or stolen and requesting replacement drugs because of addiction problems.

What is a False Claim?

A claim that violates the federal False Claims Act happens:

  • When a claim is presented fraudulently for payment;
  • Does not tell the truth on the claim;
  • Or uses false information in the claim.

One person may cause this or people may knowingly work together to cause false claims. This is illegal and should be promptly reported.

How does Navitus Help Prevent and Detect Fraud, Waste, and Abuse?

Navitus’ Special Investigations Unit (SIU) is responsible for protecting the assets of its clients and reducing the overall cost of prescription drugs by preventing, detecting, and investigating fraud, waste, and abuse. Navitus’ SIU investigates any referral from both internal and external sources. The SIU also stays current with fraud schemes and partners with pharmacies and clients on identifying potential issues.

What Can You Do?

Report your concerns! Please email [email protected], call the confidential hotline at 855-673-6503, or send a letter to Navitus’ Chief Compliance Officer at the address below. Reports can be made anonymously if desired.

Attention: Carrie Aiken
Chief Compliance Officer
361 Integrity Dr.
Madison, WI 53717

Navitus will make every attempt to maintain confidentiality, but confidentiality may not be guaranteed if law enforcement becomes involved.

Navitus has a non-retaliation and non-retribution policy for FWA reports made in good faith.

The Navitus FWA program complies with CMS requirements for effective communication set forth in 42 C.F.R. §§422.503(b)(4)(vi)(D), 423.504(b)(4)(vi)(D).

Stay Informed and Connected

Receive expert insights, healthcare tips, and important updates on pharmacy benefits, drug recalls, and more—straight to your inbox.

Examining Trends that Drive Informed Decisions

Now Available: 8th Annual Drug Trend Report

See the latest results and access industry insights you need to navigate current trend drivers.

Related blogs

Navigating Healthcare and Improving Outcomes

Achieving Outstanding Results with Tailored Network Strategies

Achieving Outstanding Results with Tailored Network Strategies

A medium-sized city in Michigan with 1,350 members was seeking ways to lower its pharmacy benefit costs, which were growing under its existing traditional pharmacy benefit manager (PBM). With its member covered by a two-tier, open formulary including…

Breaking Through Barriers with Value-Based Plan Design

Breaking Through Barriers with Value-Based Plan Design

Facing increased pharmacy benefit expenses, Blain’s Farm and Fleet, a Midwestern employer group, desired to improve plan performance. Specifically it was interested in educating eligible members about the benefits available to them, promoting cost-effective…

Finding a Solution to Lower Prescription Drug Costs

Finding a Solution to Lower Prescription Drug Costs

The Rural Arizona Group Health Trust (RAGHT) wanted to gain better control of its escalating drug trend with its large, traditional pharmacy benefit manager (PBM). Having only worked with traditional PBMs in the past, RAGHT was interested in exploring…

Empowered by Strategic Opportunities and Service Excellence

Empowered by Strategic Opportunities and Service Excellence

Putnam | Northern Westchester Health Benefits Consortium (PNW HBC) was the first municipal cooperative health plan in the state of New York to become certified by the Department of Insurance. They are dedicated to meeting — and exceeding — the standards…

QUALYiQ Program Delivers Significant Savings for Both Members and Health Plans

QUALYiQ Program Delivers Significant Savings for Both Members and Health Plans

As part of their treatment plan for hypophosphatasia (HPP), a rare genetic disorder affecting bone and teeth development, one of our members required Strensiq, a medication designed to manage HPP. However, Strensiq’s annual treatment costs ranged from…

RISE: Reporting and Intervention for Stars Excellence

RISE: Reporting and Intervention for Stars Excellence

RISE is a comprehensive Star Ratings Improvement program that focuses on positive outcomes for Medicare Part D (Part D) clinical measures, including: medication adherence for diabetes medications, medication adherence for hypertension, medication adherence…

Medication Therapy Management: Improving Health Outcomes and Reducing Cost

Medication Therapy Management: Improving Health Outcomes and Reducing Cost

Patients with chronic diseases can face greater risks for medication-related challenges such as non-adherence. This can lead to poor health outcomes and higher plan costs. That’s why we developed an MTM program, offered through our Clinical Engagement…

Personalized Member Transitions: Creating a Smoother Benefit Transition

Personalized Member Transitions: Creating a Smoother Benefit Transition

Navigating benefit transitions is no easy task. Our personalized member transition (PMT) program makes it smoother for both plan sponsors and members. Through our high-touch outreach to members, we eliminate gaps in care, minimize member disruption, improve…

Pharmacy and Practitioner Exclusions and How to Resolve Them

Pharmacy and Practitioner Exclusions and How to Resolve Them

Prescribers and Pharmacies can be deemed ineligible for providing services to government programs like Medicare, Medicaid or even to payers who are participating in government programs. Being ineligible to provide those services is commonly referred to…

previous arrow
next arrow