Uncovering Prescription Drug Fraud, Waste, and Abuse during COVID-19

New research shows that every $1 of fraud, waste, or abuse costs $66 in related expenses. This is true even during a pandemic.
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Drug fraudsters have adapted schemes to take advantage of COVID-19, but our Enhanced Fraud, Waste & Abuse (eFWA) team continues to combat these efforts and modify its approach to curtail new strategies.

Medication fraud, waste, and abuse unnecessarily costs plan sponsors and puts their members’ safety at risk. Express Scripts’ internal research has uncovered that for every $1 spent on illegitimate narcotic prescription claims, an additional $66 is incurred in medical claims related to office visits and outpatient treatment. This adds up to billions in avoidable costs.

We are now seeing cases that involve drugs associated with the COVID-19 pandemic, such as hydroxychloroquine, dexamethasone, high-cost multivitamins, HIV antiretrovirals, and azithromycin. Like the aforementioned narcotics, drugs dubiously touted for COVID-19 are relatively cheap and coincide with medical claims for acute care. It is likely prescription claims for these drugs are only a fraction of the cost.

Since the pandemic was declared in March 2020, our teams have been able to quickly adapt their techniques and methods to include early communication with prescribers when patterns are uncovered. They have investigated more than 30 unique cases involving 22 prescribers and 18 patients related to the pandemic, in addition to “typical” investigations. Our results are almost immediate, thanks to prescribers being receptive to our efforts.

Stockpiling COVID-19 Medications: A Family Affair

An Express Scripts member was identified through proactive analytics for stockpiling medications associated with COVID-19. Upon investigation, our team found that since February 2020:

  • All five members of the family were involved in stockpiling efforts. The family utilized five providers and seven pharmacies to acquire COVID-19 medications.
  • Two family members visited an emergency room (ER) on multiple occasions, requesting COVID-19 medications even though one family member repeatedly tested negative for COVID-19.
  • One family member attempted to use different names to avoid detection in the ER. Our team learned from interviewing providers that short-days’ supplies were prescribed to “placate” her.

As a result of these findings, the team referred this case to the U.S. Attorney’s Office. 

Vigilance = Savings + Healthier Outcomes

While utilization management programs guide appropriate medication use based on clinical guidelines and standards of practice, our eFWA program goes further. We identify and examine unusual prescribing patterns and unusual behavior, even as fraud, waste, and abuse patterns evolve during a pandemic. This can include doctor-shopping, identity theft, overprescribing, telefraud schemes, and other actions, which can result in overall savings for plan sponsors and healthier outcomes for members. Our eFWA Member and Prescriber program helped clients avoid as much as $150 million in prescription costs since 2019.

While the global pandemic will pass, new schemes for fraud, waste, and abuse will continue to increase. Our analysts are constantly adapting models to identify new prescription fraud schemes, which results in helping to control prescription drug cost and keeping our members healthy. While our core Pharmacy Benefit Manager offering includes an ongoing proactive review of all plan claims at the pharmacy level, we’ve found that significant cases of fraud, waste, and abuse are not limited to preparing/dispensing medication in the pharmacy setting. They are also found with providers and members.

If you or someone you know is misusing or abusing medication, you are encouraged to contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline: 1-800-662-HELP (4357).

Should you have any concerns of fraudulent usage of your prescription drug benefit, please contact Express Scripts’ Fraud Tip Hotline at (866) 216-7096.

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