Fraud, Waste, and Abuse

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. 

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.

Who does Fraud, Waste, and Abuse Affect? 

The answer is everyone. This is why Navitus Health Solutions (Navitus) is committed to ensuring it maintains a robust fraud, waste and abuse program.

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.

 

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.

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 siu@Navitus.com, 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).