Combating FWA: International Fraud Awareness Week

In 2020, the United States has seen the largest health care fraud and opioid case in history, involving 345 defendants responsible for more than $6 billion in alleged fraud losses.¹

That’s one reason why the work of Prime’s fraud, waste and abuse (FWA) team is important. Since partnering with health care analytics company SAS in mid-2018, the team has helped save over $355 million. SAS is an artificial intelligence (AI) tool that uses medical and pharmacy data to analyze potential fraud scenarios. By using risk scores and visualizations, Prime’s team can identify future FWA risks.

“Staying ahead of fraud, waste and abuse schemes is critical to maintaining the health of our members, and saving money for them and our health plan partners,” said Anne Mack, Prime’s senior director of network compliance. “Fraud, waste and abuse can come in many forms that are constantly evolving.”

Oftentimes, FWA can be pharmacists that alter prescription orders, providers that prescribe drugs for patients they have never seen, or patients that go “doctor shopping.” These are all examples of attempts to exploit risk areas. This can be tricky to spot, but when paired with SAS, Prime’s investigators can find them and leverage evidence to share with health plan clients and law enforcement.

FWA and the opioid epidemic

In addition to cost-savings, Prime’s team also works to support national efforts in managing the opioid crisis. They save lives through the investigation of pill mills and fraudulent prescriptions, while also shining light on those at the highest risk for abuse. According to the Department of Health and Human Services, over 47,000 people died from an opioid overdose in 2018. By using SAS, the team has successfully identified several forms of opioid FWA, which can be used to help curb the opioid epidemic.

In a recent case study, FWA investigators found that one member had 123 opioid prescriptions from 32 prescribers in 12 months and used 6 different pharmacies. They also visited the emergency room 78 times for pain complaints. This raised red flags, and upon confirming the drug-seeking behavior, the plan was notified of this member so they could intervene.

FWA and the COVID-19 pandemic

The COVID-19 pandemic has been no exception to the presence of fraud schemes. Early in the pandemic, one pharmacy was associated with a high volume of claims for a high cost multivitamin associated with cost spikes. While investigating these claims, the team found the pharmacy preyed on members’ pandemic fears and misled prescribers about using this multivitamin for COVID-19 prevention when there is no basis to support that multi-vitamins prevent catching the COVID-19 virus. In addition, members were told the multivitamin was free, when claims were billed to their insurance and copayments were waived by the pharmacy. Finally, the team discovered vitamins were not received by several members, and in many cases not even prescribed.

Armed with this information, the FWA investigators terminated this pharmacy from the network, reported the incident to the board of pharmacy and forwarded the case to the health plan client for potential law enforcement action.

Prime’s team is hard at work every day to prevent FWA across the country that drive up health care costs. Cases like these are the reason why Prime ranked second in the health category of the 2020 Most Innovative Companies list. Their work is crucial to helping Prime root out bad actors so we can keep health care costs affordable for everyone.

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1. https://www.dea.gov/press-releases/2020/09/30/national-health-care-fraud-and-opioid-takedown-results-charges-against