Prime halts fraud in new claims process for COVID tests

The fraud, waste and abuse (FWA) prevention team identified and stopped a pharmacy that attempted to make fraudulent claims for at-home test kits

March 24, 2022

Earlier this winter, the team at Prime Therapeutics (Prime) developed a new claims process in just four days due to a federal mandate that required insurance companies to cover at-home COVID test kits.

With a major uplift like this, fraudsters oftentimes try to exploit gaps. But Prime’s fraud, waste and abuse (FWA) prevention team was prepared and had a plan ready.

Six days after the claims processing solution was implemented, Prime’s FWA analytics team identified its first case of fraud.

The pharmacy in-question submitted 411 claims from Jan. 21-24, 231 of which were for a specific brand of COVID test kits. Later, Prime learned that the pharmacy fraudulently submitted claims for nearly all the patients in their system. Prime contacted multiple patients, who denied ever requesting or receiving the kits. In one case, a member said the pharmacy billed tests to their insurance without permission.

As a result of the investigation, the pharmacy reversed all the tests they had billed, saving clients about $20,000 in claims and stopping the behavior within two weeks of it occurring.

Prime has since taken steps to terminate the pharmacy from its network.

“I am proud of the way Prime’s FWA prevention team handled this incident. While the savings that resulted from this investigation are significant, halting this behavior quickly is even more important,” says Mitchell Scott, director, special investigations unit. “This case is just one of many ways Prime’s team works to prevent FWA and protect our members.”

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