Prime’s Special Investigation Unit: A rockstar team

A national health care fraud prevention conference may be the last place you’d expect to see rock stars. Then again, when the Prime’s SIU and pharmacy audit team has the chance to talk about their work, you might just change your mind.

Last month, two members from Prime’s SIU team, Jared Mendoza Duenas, SIU director, and Casey Jenness, senior clinical pharmacist, attended the National Health Care Anti-Fraud Association (NHCAA) Annual Training Conference in Orlando. There, they presented their latest pharmacy and prescriber case study. And among the scores of health insurers and frontline government agencies in attendance, they made quite an impression.

“Jared and Casey truly were rock stars,” Mitchell Scott, senior director of Prime’s SIU and pharmacy audit team, said. “After the presentation, people were lined-up to speak with them and hear more.”

Traditional fraud, waste and abuse (FWA) models require health plans to investigate medical and prescriber claims, while most pharmacy benefit managers (PBMs) handle pharmacy-related cases. This can leave a gap in the system where fraud can flourish.

Prime’s SIU team works alongside health plans to leverage best-in-class predictive analytics and FWA products – a unique one-two punch that can detect fraud and fill the gap.

In their presentation, Prime’s SIU team shared a 2021 case where one Texas pharmacy had filed zero pharmacy claims one month, only to file hundreds of thousands of dollars in claims for high-cost drugs – including steroids, anti-inflammatory and headache medications – the very next month. What caught the attention of Prime’s SIU team was that these claims were more than 10 times higher than other area pharmacies.

“Several patterns emerged, but what was most telling in this case was that most of the prescriptions were being filled for out-of-state customers,” Jared Mendoza Duenas, Prime’s SIU director, explained. “This was highly-irregular for what was described as a ‘community pharmacy.’”

Once all the data has been validated in a particular case, the SIU team can refer them to the health plan clients, which may in turn be shared with external investigators where appropriate action can be taken.

“Fraud of any kind puts undue pressure on our health care system, but the volume of high-cost drugs we see in these false claims is especially problematic when you consider the costs and the impact it can have on patients who truly need these live-saving medications,” Casey Jenness, senior clinical pharmacist, added.

In 2021 alone, Prime’s SIU team saved members a whopping $349 million and recovered $58 million through its audits and investigations.

With results like that, it’s no wonder Prime’s SIU team are considered rock stars.

For more information on Prime’s SIU team, check out this recent article with Mitchell Scott.