Taking precautions against pharmacy benefit fraud, waste, and abuse can protect the financial and health well-being of plan sponsors and their participants. By educating plan participants and raising awareness about the potential actions of pharmacies and practitioners, participants can support the initiative.
Identifying Fraud, Waste, and Abuse
Fraud, waste, and abuse happens every day and can easily go unnoticed by pharmacy plans and participants. Patients, providers, and pharmacies can all contribute to unnecessary spend, knowingly or unknowingly.
Fraud
Fraud, regarding prescription drugs and benefit plans, is intentionally executing or attempting to execute a ploy to deceive a pharmacy benefit plan for resources or monetary benefit. A few examples include:
- Dishonest behavior to acquire prescriptions
- Unjustified prescription writing by providers
- Billing patients for services that were not performed
Waste
Waste relates to mishandling prescriptions or performing ineffective processes, resulting in a disservice to patients and benefit plans. A few examples include:
- Patient lack of adherence to a prescription drug
- Over-supplying medications to patients
- Dispensing a brand-name drug that has a generic counterpart
- Dispensing a high-cost/low-value drug
Abuse
Abuse can comprise payments for items or services with no legal entitlement where the provider not knowingly and/or intentionally misrepresented facts for the payment. A few examples include:
- Receiving prescriptions for illegitimate medical conditions
- Early refills for controlled substances
National CooperativeRx’s Strategies for Combatting Fraud, Waste, and Abuse
National CooperativeRx has a dedicated team of in-house pharmacists who help detect and prevent prescription drug fraud, waste, and abuse. Our clinical initiatives, offered at no additional cost, include:
High-Cost Claims Review
High-cost claims reviews are a daily examination of new claims over a specific dollar threshold. These reviews confirm safety and appropriateness and explore the potential for lower-cost alternatives. When lower-cost alternatives are available, our team personally contacts patients, pharmacies, and prescribers to inform and educate them. They also review rejected claims and profiles for appropriate billing and maximize outcomes through dose optimization and therapy interchanges.
Supplemental Formulary Management
Our recommendations minimize non-essential drug spending that raises plan sponsor and participant costs. Our supplemental formulary management program guides participants to the most clinically appropriate and lowest-cost treatment options. We make this possible through surveillance of high-cost/low-value medications, scrutiny of medical foods and devices, and stewardship of medical and dental drugs.
Pharmacy Network Oversight
Since its inception, our pharmacy network oversight initiative has saved members millions. This initiative identifies pharmacies and practitioners who drive low-value medications. They are removed from our network, protecting our members from scams and questionable practices.
Advanced Criteria Updates
Our advanced criteria updates initiative assesses new-to-market or high-cost drug categories. This ongoing process is a proactive examination of drug categories that have the potential for inappropriate use.
Specialty Prior Authorization Carveout
Specialty prior authorization carveout is new as of January 1, 2023. This high-touch clinical review is led by our in-house pharmacists to confirm specialty medications are suitable for our plan participants’ clinical needs.
Outside of clinical initiatives, National CooperativeRx enlists an independent firm to audit every claim for financial accuracy and claim adjudication.
As a member-focused cooperative, National CooperativeRx will continue to defend its members from unjust acts by pharmacies and practitioners and utilize proactive approaches.
If you are a plan sponsor interested in implementing National CooperativeRx’s clinical initiatives, please reach out to your National CooperativeRx strategic account executive.
Click here for an educational flyer about fraud, waste, and abuse.
