2023 NHCAA Rewind – The Prime/MRx Special Investigations Unit is Prepped to Explore the Frontier of Fraud  

By Jared Mendoza Duenas, Director, Special Investigations Unit, Prime Therapeutics

November 16, 2023

Earlier this month, the Prime Therapeutics/Magellan Rx (Prime/MRx) Special Investigations Unit (SIU) and Fraud, Waste & Abuse (FWA) Analytics team participated in the 2023 National Health Care Anti-Fraud Association Annual Training Conference (NHCAA ATC) in Dallas.  

Prime's SIU Team at the NHCAA.

(l to r) Jaye Detlefsen, Prime; Mitch Scott, Prime; Lynn O’Dea, Director, HCSC Special Investigations Department; Jared Mendoza Duenas, Prime

This annual event sees scores of health plan administrators, law enforcement officials, and state and federal regulators gather to share information and the latest investigative trends to better enable the detection, investigation, prosecution, and prevention of FWA. But at its core, the ATC bolsters our ability to strengthen the public/private partnerships that powers the organization’s work.

As is the case with so many other industries, a key topic of discussion was the impact of artificial intelligence (AI) in the FWA space, not only on the side of prevention, but also as a tool used by perpetrators. Technology has enabled perpetrators to create false medical records, prescriptions, x-ray images, and even some schemes using text-to-speech technology to imitate members.  

While the role of AI in FWA is rapidly evolving, it was good to see how Prime/MRx is already leveraging technology and analytics in ways that are consistent with best practices discussed during the ATC. For example, the FWA Analytics team uses machine learning models to identify new cases, which is a technique that will only grow in importance as new, technology-driven fraud schemes evolve and become more common. 

It also was powerful to see case studies and best practices from both the private and public sector. In one such presentation, we learned more about how the popularity of GLP-1 drug use for weight loss has driven an alarming number of scams in recent years. As was the case with GLP-1s, social media influencers can propel off-label use of these drugs, which can drive-up demand and cause shortages for people who have legitimate medical need for these drugs. Fraud thrives in environments like this, and it’s a potent reminder that the public and private sector must be coordinated and nimble to respond to emerging trends.  

Other presenters shared how schemes involving Durable Medical Equipment – such as wheelchairs, walkers, at-home blood testing equipment, etc. – and dental fraud, among others, are also becoming more sophisticated. While schemes like these may not directly impact us as a PBM, it enabled us to see the complex and interconnected nature of FWA and how Prime/MRx can best partner with clients to mitigate a host of other schemes.  

A key takeaway for me, however, was that while the FWA space is rapidly changing, our SIU team is “small but mighty.” In fact, of the investigative techniques explained and shared during the ATC, I was pleased to see that our team has already implemented many, like machine learning in analytics, as standard practices in work. But that doesn’t mean we don’t have room to grow or improve.  

As we look ahead to 2024, we will continue to prioritize collaboration with regulatory agencies and law enforcement across the U.S. After all, partnership and information sharing are two of the best tools we have to confront and prevent FWA that not only puts the health of individuals at risk, but also drives-up health care costs. 

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