Health care fraud, waste and abuse (FWA) poses an enormous risk to patients, providers and payers. According to the U.S. Department of Justice, health care FWA accounts for up to 10% of overall spend.¹ That means about $100 billion is lost every year as a result of schemes that can be difficult to detect.  

In this episode of the Pharmacy Friends podcast, “Shielding against pharmacy deception,” Mitch Scott — senior director, Special Investigations Unit (SIU) and pharmacy audit — joined Maryam Tabatabai, PharmD — vice president of clinical information — to share how the Prime Therapeutics (Prime) SIU works to protect clients, members and employees from bad actors looking to take advantage of others through the health care system.  

“There’s work to be done, but if everything we’re doing saves just one life, it’s worth it,” Scott said. 

Prime’s FWA programs include processes designed to detect and prevent schemes across the entire drug-prescribing continuum — from prescriber to pharmacy to members — and includes all in-network pharmacy types, including retail, mail, online and specialty. Prime collaborates with regulatory agencies and law enforcement across the United States, sharing the latest tools and information to confront and prevent FWA.  

“When I think about the work that we do at Prime, we really do try to challenge the norms,” Tabatabai said. “Medications, certainly, we want them to be more affordable, but ‘save’ also means saving lives and helping people achieve better health.” 

In this episode, Scott shares more about Prime’s FWA solutions, which uniquely examine member and prescriber fraud in addition to pharmacy fraud, which has helped members save hundreds of millions of dollars.²   

“We want to have systems in place that we’re holding people accountable and recouping funds, because we all know that in this industry when things are not held in check, that drives up cost,” Scott said. “It drives up the availability to get medication.” 

Pharmacy Friends is a podcast dedicated to bringing industry experts to the same table to talk about what is happening in pharmacy today, what is coming and, most importantly, what it means to you. Listen to the full episode “Shielding against pharmacy deception” on PrimeTherapeutics.com/Listen. 

For the latest tips, trends and topics relating to fraud, waste and abuse (FWA), check out Prime’s Fraud Focus content series, where experts from the Special Investigations Unit (SIU) share common FWA schemes and how to identify and avoid them.  

References

1. 976. Health Care Fraud—Generally. Justice Manual | 976. Health Care Fraud-Generally | United States Department of Justice. (2020, January 21). https://www.justice.gov/archives/jm/criminal-resource-manual-976-health-care-fraud-generally  
2. LLC, P. T. (2021, August 11). Prime Therapeutics’ advanced fraud, waste and abuse program saved its health plan clients $285 million in 2020. PR Newswire: press release distribution, targeting, monitoring and marketing. https://www.prnewswire.com/news-releases/prime-therapeutics-advanced-fraud-waste-and-abuse-program-saved-its-health-plan-clients-285-million-in-2020-301352999.html