Three Minutes with Mitchell ScottNovember 15, 2022
Mitchell Scott is Senior Director of Prime’s Special Investigations Unit (SIU) and Pharmacy Audit team. Before joining Prime in 2019, he served for more than two decades in law enforcement positions, including patrol officer, detective and chief of police for a suburb in the Minneapolis-St. Paul metropolitan area.
Why is it important for Prime to have a dedicated team focused on FWA?
Member service is important to Prime. We want to help ensure members receive the best care when accessing their prescription drug coverage. Our biggest concern is risk management which can divert away from necessary care, cause higher copays and overall costs – which can impact clients and members. Our team is the corporate watchdog to help prevent bad things from happening. And when we see it, we work with regulatory authorities to hold people accountable for their actions.
Your team members come from incredibly diverse professional backgrounds. Can you share the types of people on your team and what value they bring to your work?
Our special investigation unit (SIU) team has a wide variety of professional experience – and that really is our strongest asset. We have staff with law enforcement background, private investigators, financial crimes experience, registered nurses, pharmacy technicians and pharmacists. Because of this diversity, we all look through different lenses when we conduct investigations. We all see things differently, pull in different factors, different angles, different visions and different experiences. We partner. We learn. We become better. We have such a great team, great leaders and we do our jobs very well.
You left your position as Chief of Police to come to Prime’s special investigation unit to fight fraud, waste and abuse in health care. Why did you decide to come to the private sector, and specifically Prime?
As the Chief of Police, I became very comfortable in my job. I worked in the law enforcement field for 32 years. I understood everything about that career. I had seen it all. I wasn’t looking at retiring, but when the SIU director position at Prime opened, I dove in and educated myself on what a pharmacy benefit manager is and evaluate how I could bring my leadership skills to the job.
You have set up an incredible connection with Prime’s health plan clients through the Special Investigation Units at Prime and the plans. How does that relationship benefit the parties and members?
We do have great relationships and connections with our clients and the SIU units at the health plans. We work in tandem with them, with the shared goal of combatting fraud, waste and abuse. Their focus on medical side drugs complements our integrated medical plus pharmacy view to drive collaboration. Having this full scope of activity has allowed us to offer more comprehensive programs to our clients and do more for them.
How has your work changed through the COVID-19 pandemic?
Individuals try to capitalize on people’s fear – and there was a lot of fear during the COVID-19 pandemic, especially at the beginning. Like other schemes, the COVID-19 schemes kept evolving but Prime was on top of it. It went from schemes about certain drugs, to over-the-counter tests, to physician-administered tests. We acted quickly and did a great job to build models to catch pharmacies and providers billing false claims.
You’ve probably seen some rather “interesting” schemes and cases in your time. Can you share (without disclosing PHI) one of your most memorable examples?
One great example shows internal collaboration between our pharmacy audit team and our SIU team. An auditor had identified a pharmacy had billed Prime for approximately $1.9 million which was associated to one prescriber for high-cost low-value products. The SIU team initiated an investigation into the pharmacy’s behavior. The pharmacy investigator determined that an onsite investigation was warranted. The Prime investigator partnered with a client and the State Board of Pharmacy to conduct an unannounced onsite investigation. During the onsite, the investigators discovered a high volume of returned medications rejected by members and the pharmacy failed to reverse the claims submitted for those members. Additionally, the pharmacy did not have any drug stock on shelves, however, the pharmacy billed Prime and other PBMs for well over $1 million dollars. Pharmacy staff also provided false and/or misleading information to the investigative team. The Board of Pharmacy investigator seized prescription records and prescription drugs and placed a chain on the pharmacy door to prevent further business.
What’s next for the fraud, waste and abuse team at Prime?
We are always trying to improve our work and our product offerings to our clients. We are trying to be proactive looking at new drugs coming in to evaluate what’s the next issue so we can be best prepared. How can we better serve our clients and members!
We also have a couple pilots in the works to help guide our next steps. Stay tuned for more information on that.
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