While it sounds like an exaggerated word problem from a math class, one recent fraud case identified by the Prime Therapeutics (Prime) Special Investigations Unit (SIU) amounts to a potentially dangerous situation for the individual involved and downstream impact for other asthma patients. 

Asthma inhalers — including preventative inhaled corticosteroids like fluticasone (Flovent) or quick-relief short-acting beta agonists (SABAs) like albuterol (Ventolin, Proventil) — can help manage the symptoms of this chronic lung condition, which causes inflammation and narrowing of the airways, making it difficult to breathe.   

However, clinical studies show that inhalers can be misused to achieve mild stimulation, euphoria and intoxication, in addition to perceived sympathetic stimulation — such as a racing heart, increased alertness and expanded lungs.  

After receiving multiple fraud, waste and abuse (FWA) hotline reports, the SIU investigated and found that one member received a 12,187-day supply of 19 unique inhalers from more than 85 pharmacies and over 65 prescribers over the course of two years, most likely for potential misuse or resale. This had a $174,000 impact on the member’s insurance company.  

It can be extremely dangerous for asthma patients to use multiple inhalers without a provider’s knowledge. Doing so may increase the risk of drug interactions and adverse events due to the duplication of therapy, or drugs using the same ingredients. It’s also possible to overdose on inhalers, causing symptoms such as a rapid or irregular heartbeat, high blood pressure, tremors or shaking, nervousness or anxiety, headache, nausea or vomiting, dizziness or lightheadedness and/or difficulty breathing. In extreme cases, it may lead to chest pain, seizures, coma or death.  

When drugs are acquired in this manner, it can also create supply issues, delays and risks to the health of members who can’t obtain their necessary medications in a timely manner.  

This case opens the door to various mitigation strategies that can be used by insurance companies to better protect members and help ensure proper treatment is also cost effective. Our team worked with this member’s insurance to explore mitigation opportunities and review benefit design for potential recommendations such as quantity limits. 

Although this member’s experience is extreme, overutilizing members make up a small, yet significant, portion of overall insurance membership. That said, the Prime SIU team is here to help identify and prevent instances of FWA through products such as its Care Management solution, which offers education and resources on medication safety, ongoing monitoring to proactively mitigate any further patient safety concerns and opportunities to collaborate with health plans for member safeguards. 

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.