Prime Therapeutics says waste and fraud detection program has saved $279 million

Call it a cream scheme.

Investigators who specialize in detecting fraud and waste in the health care system say that certain telemarketers, physicians and pharmacies are exploiting gaps in the system to send out costly skin creams patients don't need. The scheme is not new, but it has been aided greatly by the conveniences of telemedicine, electronic prescribing and even surveys on Facebook.

Prime Therapeutics, the Minnesota-based pharmacy benefit management (PBM) firm that works for 23 different Blue Cross plans, said it has saved $279 million in the first year of a new program to combine massive health care data sets in ways that reveal sources of waste, fraud and abuse, including cream schemes.

In one recent case, a patient who is blind was confused about why an investigator from Prime said there were prescriptions filled for two skin-cream drugs. A doctor had told the patient there was just one. But when an aide checked the bottles, they contained two different kinds of creams. "I wondered why it only worked some of the time," the patient told the Prime investigator.

Prime reclaimed some of the funds involved in that case, terminated the pharmacy from its network, and reported the incident to regulators, a spokeswoman said. No law enforcement agency has yet picked up the case, which isn't uncommon because of the sheer volume of health care fraud in the system. Medicare alone had more than $30 billion in "improper payments" for hospital and physician care and durable medical equipment in 2018.

PBMs typically have programs to detect fraud and waste in drug prescribing, but not necessarily in hospital or physician care.

Prime has started integrating medical data from its Blues plans with the prescribing data it has traditionally focused on, allowing it to detect problems at a higher rate by breaking down barriers that have allowed fraudsters to escape detection.

"We can now pull in the medical claims that were associated with them getting those $300 worth of scripts. It could be half a million dollars of medical claims, for them going to ERs to get CT scans and MRIs, X-rays, other types of services that compound over time, for them to get those $300 worth of scripts," Abou Nader said. "So that's a much more valuable case for a health plan, to put that all together in one, as opposed to saying, we just have a $300 drug-seeker case."

Only about half of the cases referred back to providers involved intentional fraud or waste. Others are what Abou Nader called "fat finger" errors at pharmacies, like when a single unit of a 30-day specialty drug gets mistakenly billed as 30 units, increasing the cost 30-fold.

So far in 2019, the integrated-data approach to fraud, waste and abuse prevention has led to 721 cases being referred to payers involving actions by patients, doctors, and pharmacies.

Since June 2018, when Prime first announced its integrated approach to the problem using tools developed by North Carolina analytics firm SAS, the work has led to $51 million in recovered payments and another $228 million in "cost avoidance." Prime audits its pharmacies daily in addition to its longer-term retrospective audits, and actively follows up on tips made to its hotline.

In situations where plan members think they might be unwitting participants, like in a cream scheme, authorities said patients should closely read their explanations of benefits to make sure they know all of the items being billed to insurance companies, and use fraud hotlines to report suspicious activity.