April Fraud Focus: The latest schemes and FWA trends

As the saying goes, “life is full of surprises,” and unfortunately, the same is true for the fraud landscape.

The Prime Therapeutics/Magellan Rx Management (Prime/MRx) Special Investigations Unit (SIU) continues to see reports of fraud schemes that have kept us on our toes. Which is why we are pleased to present our April Fraud Focus – a month of content to report on the latest schemes and to arm you with tips that can help protect you and your loved ones from fraud.

One such trend is related to glucagon-like peptide-1 agonist (GLP-1a) drugs for weight loss. The incredible demand for GLP-1a drugs – for both weight loss and diabetes therapies – has meant that some providers may turn to other sources, or even fraudulent means, to sell to consumers. And as we described in a blog post earlier this year, the FDA has been investigating some claims of counterfeit GLP-1a drugs. While it’s difficult to tell just how common counterfeit GLP-1a schemes are, most current fraud tied to these drugs have been “more conventional.”

The FDA has approved two GLP-1a drugs, Wegovy and Saxenda, for weight loss, while other drugs in the class are approved for the treatment of type two diabetes. This means some providers may falsely claim that individuals have a prior diabetes diagnosis and therefore should have access to GLP-1a drugs. Other cases involve attempts to circumvent prior authorization (PA) on these drugs with some providers falsifying that individuals have tried other treatments for diabetes or weight loss, which have failed, effectively “leap frogging” the process to access these in demand drugs.

Another scheme we have seen involves “bad actor” pharmacies billing Prime/MRx, or other payers, for prescriptions that members had never filled or received. In the cases we’ve investigated, these same pharmacies submitted invalid cash copayment receipts seeking reimbursement from Prime/MRx. In our analysis of these cases, we’ve learned that members deny making copayments of any kind, cash or otherwise.

As we always recommend when it comes to suspected fraud, “Trust your gut.” If something seems wrong, report concerns to your health plan immediately. You also can use the National Association of Boards of Pharmacy Safe Pharmacy site to identify and locate legitimate online pharmacies.

Stay tuned for more fraud tips next week, and watch for more information on X (formerly Twitter) @Prime_PBM.