Detect and prevent fraud, waste and abuse

Special Investigations Unit and Audit  Department 
Our fraud, waste and abuse (FWA) programs combine clinical safeguards with advanced investigative solutions to help address FWA across the pharmacy experience. 

Anyone can report FWA

It’s everyone’s responsibility to report FWA — that includes members, providers, pharmacies and even the general public. Here are the ways you can report suspicious activity at Prime Therapeutics (Prime):

Understanding and eliminating FWA

Prime’s approach to FWA is rooted in integration, collaboration and accountability. Our Special Investigations Unit (SIU) and audit department analyzes pharmacy and medical data together and partners closely with our clients to understand how we can address their challenges and produce outcomes that protect healthcare dollars and prioritize patient safety.

We address FWA through an integrated set of tools and products designed to detect, investigate and remediate suspicious activity, including:

  • FWA analytics and industry alerts
  • Pharmacy investigations and requests for information
  • Daily desk and on‑site audits
  • Post point‑of‑sale review
  • Pharmacy collections and recovery
  • Member and prescriber investigations (through our Advanced FWA solution)
  • FWA clinical remediation

Clinically led capabilities 

Prime offers a two-tiered approach to identifying and eliminating FWA: Core and Advanced. And because our approach is clinically led, you get near-real-time insights that help improve the efficiency of your clinical and medical processes. 

Core FWA

Prime's FWA department serves as the first line of defense, helping prevent and reduce FWA before it occurs.

  • FWA hotline intake
  • Pre-credentialing FWA reviews and denials
  • Daily and historical claim audits
  • On-site pharmacy audits
  • Pharmacy audits and investigations
  • Pharmacy education
  • High-quality pharmacy network oversight
  • Formulary change recommendations and management
  • Benefit configuration recommendations

  • External reporting to health oversight agencies

Advanced FWA

Prime’s clinical products serve as the first line of defense, helping prevent and reduce FWA before it occurs.

  • All Core FWA products
  • Member and prescriber FWA investigations
  • FWA member care management
  • Prescriber education
  • Prescriber remediation strategies
  • CMS-mandated reporting

Our collaborative approach

When it comes to addressing FWA, Prime doesn’t do it alone. We work alongside our clients, partnering throughout investigations, sharing insights, identifying potential issues and focusing on meaningful outcomes. We set ourselves apart from the standard industry experience, offering:

Integrated pharmacy and medical data analysis

Close collaboration with client investigation units

Ongoing consultation on FWA trends and schemes

Results-driven investigations with transparent reporting 

$1.5B

In the last five years, Prime’s FWA programs created $1.5B in overall value for clients through audits and investigations.

Prime Therapeutics internal data, 2026

Meet our people

“If the work saves just one life, it’s worth it.”

- SIU team motto

Mitchell Scott
Senior Director, SIU & Pharmacy Audit
Jared Mendoza Duenas
Director, SIU
Casey Jenness
Director, FWA Clinical Support Services
Vanessa Emlich
Director, Pharmacy Audit Operations

Reporting FWA is simple and annonymous. 
If you see something, say something. 

Comprehensive, connected compliance

Prime’s FWA programs are supported by deep cross-functional expertise, including former law enforcement, clinical professionals and certified fraud examiners. Learn how our experts are helping everyone stay ahead of the curve.