Fraud, waste and abuse (FWA) costs the U.S. health care system more than $100 billion every year, according to the U.S. Department of Justice.   

The Special Investigations Unit (SIU) at Prime Therapeutics (Prime) is a trusted partner when it comes to the identification, prevention and education of FWA across the health care continuum. Our team plays an active role in keeping members safe, as we often say that any effort to save a life is worth it. I enjoy connecting with clients and members, hearing their experiences and educating them about benefits and resources to empower their health care journey. Our team takes access to care, patient autonomy and cost of care seriously, and we strive to build a collaborative approach with clients to make health care systems safer and more secure.   

That’s why I’m thrilled to introduce our newly enhanced Care Management feature, which provides additional assessment and ongoing monitoring options for clients to help identify and support at-risk members. This offering helps eliminate the stigma surrounding lock-in programs (also known as patient review and restriction programs) and offers a more holistic approach with the member in mind.  

Customized Care Management options include:   

• Pharmacy and provider outreach   
• Member safeguards   
• Reporting and claims monitoring   
• Clinical support, education and resources   
• Holistic nursing assessments  

The Care Management feature is customizable and can include member case management for clients that may not offer such services. It can help to reduce patient safety risk, reduce barriers in obtaining medication and mitigate a lack of care coordination. Through additional outreach and education, members gain a better understanding of their conditions, benefits and available resources.   

FWA can occur because members lack information and experience barriers to care. For example, they may seek out continuous care through the emergency room as opposed to a primary care provider, or use multiple pharmacies, which can put them at risk for adverse events due to a lack of holistic medication oversight. By expanding our focus to include education and resources, we aim to empower members to access care in a different, better way.  

At Prime, we’re excited to continue to evolve how we confront FWA. This solution is an offering included in the Advanced FWA product, which Prime has offered since 2020.    

As always, 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.