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Identify FWA at Pharmacy, Provider, & Patient Levels for Interventions and Correction

FWA is not one point in time. It is a trend. Prevent it before it happens!

    How do we address FWA?
  • IDENTIFY the offenders (fraud)
  • PREVENT abuse and waste.

FWA can occur when prescribers, patients, or pharmacists err for several reasons – e.g., intentional fraud, careless waste, or abusive behaviors. Management must approach the problem using multiple strategies.

    Our strategies focus on prevention while targeting the most egregious offenders for fraud.
  • What are the intervention opportunities?
  • What interventions are possible at point-of-sale?
  • What are the opportunities for preventing further abuse or waste?


Fraud, Waste & Abuse at Work

Problem: Fraud is generally rare, expensive to prove, and requires attorneys to pursue and prosecute. Medicare and Medicaid have emphasized prevention as the preferred route. As a result, the target is to prevent fraud, waste and abuse. Pharmacy Benefit Managers (PBMs) address the problem at point of care. However, prevention requires behavior changes that must be accomplished through regular and consistent communications including peer-to-peer comparisons. One of our health plans requested a solution in addition to their PBM approach which we have detailed below.

Methodology: We deployed a solution that had been validated in a multi-year provider intervention. A study group was age/gender/specialty/severity/geographically matched with a control group. Hundreds of compliance metrics were analyzed electronically with emphasis on opiates, scheduled agents, timing of prescription fills, quantity/days' supply, and other Plan pre-selected metrics. All study and control providers were statistically analyzed in historical data to ensure that providers who trended above matched averages were grouped into probability bands. For example, in probability quartiles providers were placed into high risk pools for potential fraud, waste or abuse. The providers were analyzed each month and reported in comparison to their matched peers. Every provider was trended to their individual experience and to their matched peers.

Outcome: Over the first year, and subsequently and ongoing, study group providers demonstrated improvements in selected metrics and costs on a per-utilizer-per month (PUPM) basis. PUPM reductions were in the range of 20-30% each year. Compliance with opiates and scheduled agents were reduced the most at 30-50% or more, while other metrics were reduced at 20% or more depending on the priority of each metric.

This was valuable information for the Health Plan and assisted not only with cost controls and compliance with Federal, State and National Regulatory Associations.

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