How PBMs Can Help Plan Sponsors Combat Fraud, Waste and Abuse

Posted by Navitus Health Solutions on Sep 16, 2021 8:00:00 AM

Carrie Aiken, Navitus’ Vice President of Corporate Compliance and Chief Compliance Officer, shares her perspective on how PBMs can help plan sponsors manage the risks of fraud, waste and abuse.


The U.S. health care system loses tens of billions of dollars every year to fraud, waste and abuse. In fact, the National Health Care Anti-Fraud Association estimates that health care fraud costs the nation about $68 billion annually. A large portion of these costs are attributed to pharmacy spend, including duplicate claims, data entry errors, forged prescriptions and intentional overcharging.

Pharmacy fraud, waste and abuse impacts everyone and results in misused benefits, safety issues and unnecessary financial losses. Pharmacy benefit managers (PBMs) can play a key role in safeguarding plan sponsors and their members by detecting and investigating potential fraud, waste and abuse. In turn, plan sponsors can protect their members from the risks of disrupted care and unnecessary costs by partnering with a PBM that has a holistic fraud, waste and abuse program in place or supplementing its existing program with services and tools from an additional PBM partner.

At Navitus, our robust fraud, waste and abuse program investigates the entire prescribing journey, from provider to pharmacy to member, while satisfying regulatory program standards for Medicare, Medicaid and other federal programs. Plan sponsors looking to enhance their existing fraud, waste and abuse program around pharmacy services can now partner with Navitus to discover potential outliers and supplement investigation resources. By combining our extensive experience with access to pharmacy data, provider prescribing patterns and member claims, we are uniquely positioned to offer plan sponsors support they need to prevent, detect and recover losses from fraud, waste and abuse.

Why does discovering fraud, waste and abuse matter?

Fraud occurs when someone knowingly uses false information or statements to improperly obtain payment for prescription drugs. Waste is when there is overutilization of services that results in unnecessary costs. Abuse includes actions that may result in unnecessary or increased payment for prescription drugs. In any of these circumstances, there may be opportunities to recover claims, provide education or apply controls to prevent financial loss, improve safety and support claims integrity.

Combatting fraud, waste and abuse

Whether a pharmacy sends drugs that were never ordered to a patient, a person falsely states drugs were lost or stolen and requests replacement drugs, or a pharmacy dispenses without a valid prescription, PBMs have a front row seat to uncover the issues. PBMs leverage innovative data analytic tools to identify suspicious patterns and investigate the underlying source, including:

  • Pre-payment Claim Review
  • Pharmacy Audits
  • Analysis of Industry, Program and Fraud Alerts
  • Pharmacy, Patient and Prescriber Investigations

To ensure vigilance and integrity within healthcare, we must remain committed to identifying and resolving fraudulent, abusive or wasteful behavior. By combatting these issues with experience, data and robust tools, PBMs can help plan sponsors improve healthcare performance and drive better financial results and member safety. Strong collaboration between the PBM and plan sponsor can yield the greatest opportunity to lower costs and effectively manage fraud, waste and abuse.

Carrie Aiken

Carrie serves as both the Vice President of Corporate Compliance and Navitus’ Compliance and Privacy Officer. She has more than 25 years of experience across multiple health care disciplines, including physician, hospital, home health and pharmacy, as well as contracting and revenue cycle management.

Topics: News, Insider

Subscribe Here!