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Fraud, Waste and Abuse

What is Prescription Fraud, Waste, and Abuse?
Fraud is when someone knowingly uses false information or statements to improperly obtain payment for prescription drugs.

Waste is when there is overutilization of services that result in unnecessary costs.

Abuse includes actions that may result in unnecessary or increased payment for prescription drugs.

Some examples are:

  • A pharmacy submitting claims for drugs that the patient never received;
  • A pharmacy sending drugs that were never ordered by the patient or the physician;
  • Forging or altering a prescription;
  • A person obtaining prescriptions for drugs in order to sell them; 
  • A physician writing a prescription for drugs for someone that is not a patient because the physician receives a payment;
  • A patient selling their medical ID card or prescription to someone;  
  • Using another person’s insurance coverage or insurance card; 
  • A pharmacy billing for a brand drug, when it dispensed a generic drug;
  • A claim for weight loss drugs falsely submitted with a diagnosis of diabetes so it will pay under the pharmacy benefit;
  • A person falsely stating drugs were lost or stolen and requesting replacement drugs because of addiction problems. 

Who does Prescription Fraud and Abuse Affect?
The answer is everyone.  It results in misused benefits, safety issues, and unnecessary costs which is why Navitus is committed to ensuring it maintains a robust fraud, waste and abuse program.

How does Navitus Help Prevent and Detect Fraud, Waste, and Abuse?
Navitus' Special Investigations Unit (SIU) is responsible for protecting the benefits of its clients and members and reducing the overall cost of prescription drugs. It can do this by preventing, detecting and investigating fraud, waste and abuse. Navitus’ SIU investigates referrals from internal and external sources. The SIU professionals also stay abreast of the latest fraud schemes and partner with pharmacies, vendors and clients on identifying potential fraud and abuse and identify suspicious patterns.

If you or one of your employees suspect fraud, waste or abuse, please report this activity using the FWA Reporting Form, or by calling the Navitus Hotline at 855-673-6503. Navitus has a strict non-retaliation and non-retribution policy and expects all vendors to adhere to non-retaliation for reports made in good-faith.

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