Prime Sees Major Spike in Telemedicine-Based Rx Fraud

by Jane Anderson

 

Prime Therapeutics LLC saw telemedicine schemes contribute to a 60% year-over-year increase in reported false claims from 2020 to 2021. The PBM, which is in its second full year of operating an artificial intelligence-powered fraud, waste and abuse (FWA) reduction program, reported that the program saved its health plan clients $285 million in 2020, in part because it detected telemedicine-driven schemes.

Fraud spike is unsurprising:

• "Because telemedicine is relatively new and it grew very quickly during the pandemic, it seems a good target for fraud and abuse," says Elan Rubinstein, Pharm.D., head of pharmacy benefits consulting firm EB Rubinstein Associates.
• Telemedicine schemes commonly involve billing for high-cost drugs that provide little to no benefit to members, since significantly lower-cost equivalents are available, according to Anne Mack, senior director of network compliance at Prime Therapeutics. Telemedicine also has allowed fraud to expand regionally.
• "In many cases, the member does not know the doctor or the pharmacy that sends them unwanted prescriptions," Mack says. "When our investigators go into the pharmacies, they often find piles of returned medications, unanswered voicemails and no customers. In other cases, the member agrees to order one drug but receives multiple drugs that they did not request and do not need."

Al helps PBM fight back:

• Mack says that several years ago, Prime partnered with SAS Institute Inc., which offers AI-powered, cloud-based fraud detection, to create "an advanced fraud analytic system that leverages integrated medical and pharmacy claims data, along with artificial intelligence, to detect and prevent pharmacy, member and prescriber FWA."
• Prime's FWA program is able to view integrated medical and pharmacy claims, Mack says, adding, "without that view, this work wouldn’t be possible," since "the visual link analysis" allows the fraud team to track multiple events "to pinpoint common denominators of fraudulent activities," which often are sophisticated schemes.
• Ge Bai, Ph.D., an associate professor at Johns Hopkins University's Carey Business School and Bloomberg School of Public Health, says she expects "a new equilibrium will be reached between the ramped-up fraudulent activities and the strengthened prevention and detection effort. Both parties are constantly learning from each other and upgrading their games."

From RADAR on Drug Benefits