Tackling fraud, waste and abuse in pharmacy care

The U.S. health care system loses hundreds of billions of dollars every year on fraud, waste, abuse and error.1A large portion of these errors are attributed to pharmacy spend, including forged prescriptions, duplicate claims, data entry errors and intentional overcharging.2In addition to costing taxpayers billions, health care fraud increases medical costs and even helps fuel today’s opioid crisis.

Pharmacy benefit managers (PBMs) play an important role in detecting and preventing fraud, waste and abuse. Their access to prescription claims submitted by thousands of pharmacies offers an unparalleled ability to audit and monitor claims within their respective networks. One tool – real-time, digital and desk audits –help employers and health plans save hundreds of millions of dollars per year. And most importantly, these tools ensure medication health and safety for members.

Real-time audits are the first-line of defense against fraud, waste and abuse – and can help save employers and health plans hundreds of millions of dollars per year. By executing these real-time audits, PBMs can correct claims or catch errors before clients are charged and before dispensing the medication to the member– a critical step that helps avoid disruption.

PBMs are leveraging new, sophisticated data analytics capabilities to proactively identify outlier activity in a pharmacy’s billing pattern and flag them for review. Examples of potentially fraudulent behaviors include increased billing volumes month over month, heightened claims activity for select medications, including opioids and certain topicals identified by the industry as being prone to abusive billing, and activity in HHS-OIG defined fraud strike force locations.

As a pharmacy care services company, OptumRx conducts hundreds of these investigative audits every year, and possesses the capability to, in just three seconds, score and rank the more than 1.3 billion claims it processes each year, flagging those with the highest risk.

One recent OptumRx investigative audit identified a pharmacy with an 830 percent increase in billing from one month to the next – highly unusual for any pharmacy. A detailed review of billing activity identified concerns regarding overall claims volume for compounded medications and Lidocaine ointment, a single-ingredient pain cream. A follow up, onsite review found a lack of activity associated with the billing increase, such as patient foot traffic or incoming phone calls. OptumRx ultimately uncovered an inventory shortfall for numerous medications totaling more than half a million dollars, and, as a result, the pharmacy was removed from OptumRx’s national network and the audit findings were shared with the appropriate law enforcement and government agencies.

Examples like this tell us that pharmacy fraud, waste, abuse and error are harmful and divert care away from the patient. To continue solving for these issues, PBMs must remain committed to identifying and resolving fraudulent, abusive or wasteful behavior to improve health care performance and drive better results for members and clients.



1. National Health Care Anti-Fraud Association. nhcaa.org/resources/health-care-anti-fraud-resources/the-challenge-of-health-care-fraud.aspx. Accessed August 21, 2017.
2. Report: “For Providers: Provider Fraud and Abuse Training Program,” Published by Affinity Health Plan. Accessed at www.affinityplan.org on Sept 20, 2017.

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