Patients with diabetes require specialized supplies — including insulin syringes, pens and pumps; glucose meters; test strips and lancets — to maintain their blood sugar levels and stay healthy. But these supplies are often costly, which makes them susceptible to misuse, waste and unfortunately, fraud.   

Through its routine investigative efforts, the Prime Therapeutics (Prime) Special Investigations Unit (SIU) identified a member who had obtained diabetes supplies from more than 70 unique pharmacies and over 50 prescribers, including emergency medicine and urgent care providers. Over the span of 731 days, the individual received the equivalent of a 2,682-day supply of various diabetes supplies, which was most likely obtained to sell on various websites for profit. Translated in terms of cost, based on this one case, a 12-month plan for diabetes supplies was 45% higher than the typical plan paid. 

You’re probably wondering: How did our team catch this instance of misuse? Thanks to multiple tips to Prime’s fraud, waste and abuse (FWA) hotline, the SIU team conducted an investigation and sent findings to the member’s insurance company. It’s possible the member used telehealth platforms to obtain the medical supplies, since online pharmacies may not request to see identification given diabetes supplies aren’t controlled substances. This individual also used information from other family members to obtain additional stock. In the end, the member was banned from several pharmacies. 

It's difficult to quantify exactly how many diabetes supplies are wasted as a result of FWA, as diabetic members may knowingly or unknowingly request additional supplies through multiple providers or pharmacies, or request that they’re refilled early. It’s also much easier to sell such items for profit across online marketplace platforms. However, this can cause a cost burden on insurance plans, which sometimes place limits on the number of supplies they’ll cover within a specific period, leading to increased out-of-pocket expenses for the member. It can also lead to waste, as a stockpile of supplies may expire before they’re able to be used. (And yes, even supplies like lancets and continuous glucose monitor sensors have expiration dates! Be sure to check the packaging for the manufacturing date and confirm all diabetes supplies are stored properly to ensure they’re effective.) Finally, it may lead to these supplies being unavailable for other patients who need them, as well as delays, which creates risks for patients with diabetes who need their supplies in a timely manner.   

If you suspect FWA, you can report it to your health plan or call the SIU at 800.349.2919 or through Prime’s anonymous, 24-hour compliance hotline.   

Prime’s April Fraud Focus content series aims to create conversations around health care fraud, waste and abuse (FWA). Every week throughout the month, check out new topics at PrimeTherapeutics.com/Read.