Three Minutes with Anne Mack

Anne Mack, Prime’s senior director, network compliance, keeps a close eye on scams, pharmacy mistakes and misspent dollars affecting Prime clients and their members. She’s spent a career specializing in health plan fraud, waste and abuse (FWA), compliance, audit and operations. She has helped develop and evolve Prime’s FWA program for more than a decade and was deeply involved in the FWA program enhancements that led to Prime being named by Fast Company magazine as the number two-ranked company in its top 2020 Most Innovative Companies in health care.

Give a brief overview of Prime’s fraud, waste and abuse (FWA) efforts and how they have evolved.

Several years ago, Prime committed to providing clients a best-in-class FWA program. We invested in new technology and staff, including folks with law enforcement backgrounds. We hired a data scientist, a registered nurse and others with investigative skills. We partnered with the data analytics company SAS to create a new fraud analytic model which leverages both medical and pharmacy claims. Fast Company magazine chose Prime as one of its top 2020 Most Innovative Companies in the health care category because of that new model.

Our standard FWA program is provided to all clients and covers the basics of prevention, detection and correction for pharmacy investigations. We also offer an advanced FWA program. This program expands Prime’s research and investigative services to detect potentially fraudulent, wasteful or drug-seeking behaviors among individual members and prescribers. These advanced resources and sophisticated data analyses provide an even stronger defense against FWA problems.

What are some persistent FWA issues you’ve seen over the years?

Fraud never stops. It takes different forms. One very rudimentary fraud tactic is pharmacies submitting claims for medications that were never prescribed. Sometimes, this is done through what we call ‘pop-up’ or ‘phantom’ pharmacies. They slam through a high volume of claims and then shut down. We also see members with a history of ‘doctor-shopping’ and using multiple pharmacies to fill prescriptions for opioids. More recently, use of different technologies enables fraud. Telemarketing is being used to push products and services that aren’t medically necessary. Prime has greatly sharpened our ability to detect and prevent these instances.

How did Prime’s work change in response to the coronavirus pandemic?

FWA programs rely on having controls, checks and balances in place. During the early months of the pandemic things evolved quickly. We needed to loosen some controls to help ensure members had adequate supplies and needed refills as people sheltered in place.

Did the pandemic give rise to any unusual FWA activities?

Unfortunately, some people took advantage of the situation. For instance, some pharmacies tried to convince prescribers and members to use very high-cost vitamins, which they claimed could prevent COVID-19. That, of course, was not supported by medical opinion. We also detected members stockpiling or trying to stockpile medications. In some cases, that was just a result of people’s anxiety and fears during the pandemic. But in other cases, people knew that controls had been loosened, and they tried to act on that. One change we introduced was a reverse prior authorization process. This allowed us to monitor members who were obtaining significant quantities of medications and then help ensure appropriate quantities of those drugs were dispensed going forward. Our efforts to detect and address FWA pandemic issues saved our clients about $6 million in 2020.

Have you seen fraud, waste or abuse stemming from vaccine distribution?

We haven’t seen widespread fraud, but we have seen patterns of billing errors. For example, we see members who – based on their claim history – look like they’ve received more than two doses of vaccine. We’ve done education and outreach with pharmacies, and, so far, this has just turned out to be missed appointments where pharmacies had not yet reversed the associated claim. However, this is concerning because the volume of available vaccines is growing dramatically; it’s increasingly important to carefully monitor for fraud, waste or abuse in vaccine distribution.

What new trends are emerging in FWA?

Telemedicine fraud schemes have been on the increase for the past five years or so. The more sophisticated approaches use social media and robocalls to try to obtain patient IDs. Legitimate telemedicine is much more popular now during the pandemic, but looking ahead, we believe this is the new normal. Virtual medicine brings some unique challenges and areas to watch for fraud.

We see kickbacks to prescribers and pharmacies for dispensing certain medications that are generally not needed. The member might not even be aware of the prescription until the medication shows up in their mailbox. Prime’s advanced analytics uses artificial intelligence (AI) to detect some of the new, more sophisticated fraud schemes.

What does Prime do to stay a step ahead of FWA trends?

Aside from watching industry trends and talking to clients, we continuously review a wide range of data. Our front-line daily claim auditors are alerted to fraud risks and flag potential emerging schemes so our fraud experts can swiftly respond. As new schemes or unusual billing practices emerge, we identify and act on them immediately.

How is Prime’s FWA approach unique or better than what others in health care currently do?

Prime has 23 health plan clients. The way we collaborate with our clients is a big part of our success. Not many pharmacy benefit mangers (PBMs) work with combined medical and pharmacy claim data, so this allows a much more complete view. And because we collaborate so closely, our FWA approach is really an extension and enhancement of our clients’ fraud programs.