International Fraud Awareness Week: Prime’s five efforts to fight fraud

Although International Fraud Awareness Week is a dedicated seven days to encourage organizations to be proactive about minimizing the impacts of fraud to their businesses, Prime Therapeutics (Prime) works all year to fight health care fraud. In collaboration with our health plan partners, Prime’s fraud, waste and abuse (FWA) team is committed to using its industry-leading suite of products and services to conduct investigations and audits that result in cost savings, cost avoidance and increased member safety.

In the last year, Prime’s FWA team had many notable achievements. To acknowledge this week, Prime highlights the top ‘five efforts to fight fraud’ of the year:

1. FWA program saved clients $285 million last year: Prime’s FWA team invests in sophisticated technology to identify and track savings opportunities. In August, Prime reported that during the previous year, the advanced FWA program saved clients $285 million for an 8:1 ROI – totaling $640 million in savings since mid-2018.
2. Advanced analytics positions Prime as a market leader: When an advanced analytics approach is used, finding one or two instances of fraud can lead to the discovery of emerging fraud trends. Then Prime can apply process changes and stop those trends from spreading while saving money and maintaining member safety.
3. Pill mill investigation leads to arrest: An investigation that began in December 2020 when Prime and a health plan client collaborated regarding a prescriber who may be running a pill mill concluded with the prescriber’s arrest earlier this year. The investigation resulted in a total savings of $48,000 for five different clients.
4. Telemedicine fraud schemes gain popularity: Prime observed a significant spike in telemedicine schemes over the last five years. In this telemedicine case study, footbath drugs are the pawn in these bad actors’ scheme resulting in a $258,000 fraud referral.
5. Outside experts support Prime’s findings: Public health and industry consultants echo Prime’s findings of virtual FWA increasing leading up to, and during, the pandemic. The virtual world is more vulnerable to scams and leaves members more susceptible to fraud schemes.

“We appreciate the focus International Fraud Awareness Week brings to fighting fraud,” said Anne Mack, senior director of network compliance at Prime. “The efforts of our employee teams, in collaboration with our health plan clients, all year are what bring positive health and monetary outcomes to plans and members.”