Fraud, waste and abuse (FWA) is a trending topic, but the Prime Therapeutics (Prime) Special Investigations Unit (SIU) has been on the case for quite some time, working with clients and partners in the public sector to bolster the efficiency and integrity of our health care ecosystem. FWA can lead to high costs for both patients and payers. What’s more, the inappropriate allocation of medical resources can also compromise the health and safety of patients.  

According to the U.S. Department of Justice, FWA costs U.S. health care systems more than $100 billion every year. But how does Prime help to identify and investigate those who seek to take advantage of a complex system?  

Health care fraud can involve deception to gain personal information — such as billing for services that weren’t provided or using false diagnoses to justify unnecessary tests or prescriptions. Waste involves the overuse or misuse of resources, whether intentional or unintentional, while abuse includes practices that are inconsistent with proper procedures, such as overcharging for care, providing services that aren’t medically needed or not meeting professional standards.  

The SIU at Prime is committed to identifying and investigating fraud across the health care continuum. But the team doesn’t operate alone. By collaborating with clients and regulatory agencies to proactively mitigate and report FWA, the organization is steadfast in preventing further FWA and addressing patient safety concerns for a range of schemes, including education and awareness of current fraud schemes, intervening on inappropriate drug prescribing, preventing providers from submitting false prior authorizations and pharmacies from billing from prescriptions that members did not receive.  

There are four collaborative branches to Prime’s SIU:  

• SIU, Pharmacy identifies and investigates fraud committed by pharmacies. Experts use a number of tools to help accomplish this, including pharmacy claims data, fraud tip hotline leads and predictive fraud analytics.  
• Advanced FWA Team identifies and investigates fraud committed by members and prescribers using integrated medical and pharmacy data combined with predictive fraud analytics to reduce the costs associated with health care fraud.  
• State Public Sector SIU vets potential FWA concerns and provides leads directly to each State’s Medicaid Program and conducts pharmacy, prescriber and member investigations where there are allegations of potential FWA.  
• SIU, Clinical Consultant Team reviews members and prescribers as part of Prime’s clinical remediation option programs, which are proactive solutions that promote member safety and mitigate FWA.  

Last year, Prime’s SIU detected schemes equating to about $250 million, including more than 200 member investigations that identified substance use concerns. An additional 186 investigations, including pharmacy, member and/or prescriber investigations, found $27 million in glucagon-like peptide-1 (GLP-1) receptor agonist FWA such as misrepresentation, stockpiling, doctor and pharmacy shopping, and patient safety concerns. The SIU also saved about $4 million in prior authorization fraud, such as false, altered or forged information or claims phishing and manipulation.   

If you suspect FWA, you can report it to your health plan or call the SIU at 800.349.2919 or through Prime’s anonymous, 24-hour compliance hotline.  

Prime’s April Fraud Focus content series aims to create conversations around health care fraud, waste and abuse (FWA). Every week throughout the month, check out new topics at PrimeTherapeutics.com/Read.