A view of COVID-19’s pressure on the health care system

In the spring of 2020, fear of COVID-19 swept the nation. An unprecedented strain on the health care system drew the attention of opportunistic criminals, bent on fraud. Prime’s fraud, waste and abuse (FWA) team stepped up its vigilance to watch for new schemes. It didn’t take long. Very quickly, Prime’s FWA’s team spotted some highly suspicious claims from a pharmacy.

Baby boom or crime spike?

In March 2020, that pharmacy began submitting a large number of claims for PreGenna. This high-cost multivitamin is usually prescribed to pregnant or lactating mothers. But that month, PreGenna claims accounted for approximately 61% of the pharmacy’s claim costs, at roughly $4,300 per fill.

Prime’s investigators dug in further. They found that representatives of the pharmacy were contacting members and prescribers about PreGenna. They were claiming the vitamin was a precaution against getting COVID-19. Most pre-natal vitamins process at $0 copay. The member would pay $0 out-of-pocket. Prescribers, unaware of the full medication cost, wrote prescriptions for the vitamin.

Prime’s investigation confirmed claims phishing and member steering. It resulted in $30,000 of fraudulent claims. This was fraud and an egregious abuse of member and prescriber trust — in the midst of a pandemic. The pharmacy was referred to the state’s board of pharmacy and local and federal law enforcement.

“Exploiting members during a pandemic is very concerning,” said Anne Mack, Prime’s senior director of network compliance. “And misrepresenting the drug? Hard to see this happening in the industry but it is representative of the COVID-related fraud that is out there.”

Prime aggressively identifies and roots out fraud, waste and abuse, analyzing prescriber, pharmacy and member data.

Providing day-to-day support for all members

The pandemic caused a lot of upheaval as people were asked to restrict activity. Members looked for pharmacy support like early refill overrides and extended prior authorizations. Many members turned to the convenience of home delivery.

Always top of mind for Prime was making sure that members had access to the drug therapy they needed. At the same time, Prime looked for ways to minimize overuse, avoid supply chain issues and anticipate opportunities for fraud.

Modifying processes to support stay at home efforts

In response to the pandemic, Prime and its clients took action to make medicine more available to people using a dynamic prior authorization (DPA) and submission clarification code. These changes let members refill prescriptions earlier than usual. That helped members stay safe at home for longer periods.

In some cases, it also opened up opportunities for waste. To counter that, Prime’s FWA team created a reverse prior authorization (PA) process. The reverse PA limited additional refills for members who had received excessive during the COVID-19 emergency period. This was a custom process, designed and implemented specifically to combat fraud during the pandemic. It saved clients over $6 million in costs, while still supporting that members received necessary medications.

Prime and its Blue Plan clients continue to work to provide the care members need and still aggressively monitor for fraud and waste in the system. Anne Mack added: “We’re here to protect our clients and their members from unnecessary costs or harm to their health.”