Tackling fraud, waste and abuse in pharmacy care

PBMs can play a key role in identifying and limiting fraud, waste, and abuse by conducting real-time audits of pharmacies' prescription claims, writes Heidi Lew, PharmD, vice president of Pharmacy Network Audit at OptumRx.

PBMs can play a key role in identifying and limiting fraud, waste, and abuse by conducting real-time audits of pharmacies' prescription claims, writes Heidi Lew, PharmD, vice president of Pharmacy Network Audit at OptumRx. These tools can help save employers and health plans hundreds of millions of dollars each year, and also guarantee medication health and safety for members. Real-time audits allow PBMs to correct claims or spot errors before clients are charged and before the drug is dispensed. Using new data analytics capabilities, PBMs can preemptively detect outlier activity in billing patterns and flag them for review. Examples of potentially fraudulent behaviors include increased billing volumes month over month, rising claims activity for select medications, and activity in HHS-OIG defined fraud strike force locations. As a pharmacy care services company that conducts these investigative audits, OptumRx can score and rank the more than 1.3 billion claims it processes each year in just seconds, flagging those with the highest risk, according to Lew.