In its first year deploying an enhanced fraud, waste, and abuse (FWA) program, Prime Therapeutics LLC (Prime) achieved overall savings for its health plan clients of $279 million. This savings included recovering $51 million and $228 million of cost avoidance through audits and investigations while focusing on the core areas of retrospective analysis, potential erroneous spending and pharmacy examinations. In June 2018, Prime announced plans to expand its FWA efforts to identify additional areas that are prone to activity, reduce the risk for clients by taking actionable outcomes and recover overpayments due to fraudulent claims.
Prime created a way to comprehensively identify and eliminate FWA. Formulary development and management, pharmacy networks, and pharmacy education provide a first line of defense to identify and remove most FWA. While other pharmacy benefit managers also provide this first step of FWA prevention, Prime’s unique and enhanced program uses the following comprehensive methods:
- advanced analytics using integrated medical and pharmacy claims data,
- pharmacy, member and prescriber investigations,
- a FWA hotline,
- daily analysis and retrospective audits,
- onsite audits, and
- collaboration with health plan special investigation units.
The National Health Care Anti-Fraud Association (NHCAA) estimates that the financial losses due to health care fraud are in the tens of billions of dollars each year.1 Prime’s ability to integrate medical and pharmacy claims data to feed the analytics engine is key to its program’s success.
“Without integrated data, we would not be able to identify the pharmacies, prescribers and members who are abusing the health care system and adding wasteful costs into the process,” said Jo-Ellen Abou Nader, vice president of fraud, waste, and abuse and supply chain optimization at Prime. “Partnering with health plan clients for this data and investigations, as well as bringing information to government agencies and industry partners, creates actionable outcomes that are improving safety and saving money.”
Controlled substances are one of the most prevalent drug classes for fraud, waste and abuse.2 For example, Prime confirmed that in a 12-month timeframe, one member received 48 prescriptions for controlled substances from multiple prescribers and multiple pharmacies. Despite multiple prescribers being involved, one single prescriber accounted for the majority of the member’s controlled substance claims, and the member previously worked at the same clinic as that prescriber. Prime also learned the prescriber’s script pad was stolen. The member was seeking drugs from many providers, and because Prime can also analyze medical claims, it was also known that the member had opioid dependency. Prime identified and addressed both patient safety and criminal behavior in this situation. These types of efforts have seen an ROI of $30:$1 on medical claims savings on spending for controlled substance claims.
“Getting ahead of crimes is the best way to prevent it,” said Abou Nader. “We’re using data to improve our predictions on fraud, waste and abuse risk. There is more opportunity to identify ‘bad actors’ in other parts of our health care supply chain. Pharmacy benefit managers are working on behalf of clients and consumers to help make health care safer, more efficient and more cost effective in the long run.”