Just as members should not have to pay more for their prescription drug benefit than their benefit specifies, neither should employers or health plans have to pay for fraudulent, wasteful, or abusive use of the pharmacy benefit. Conducting a pharmacy FWA audit is one of the most effective ways to preserve the integrity of the pharmacy benefit, avoid monetary losses, and protect members from potentially serious and costly harm.
Statistics show that abuse of opioids, including many common prescription painkillers, has reached almost epidemic proportions in the United States. The Centers for Disease Control and Prevention (CDC) reported that the number of drug-overdose related deaths in the US had reached an all-time high of more than 50,000 in 2015, driven largely by increasing abuse of prescription opioids. Of the more than 20 million Americans who abused substances in 2015, about 10%, or 2 million, had a disorder involving prescription pain killers, according to the American Society of Addiction Medicine.
It’s not just individuals with addiction problems who game the system. There are also unscrupulous physicians and pharmacies that commit fraud to make money. For example, fraudulent prescription compounding occurs when a pharmacy combines two relatively low-cost drug products – and then tacks on a huge markup – to the total drug dispensing invoice before submitting the claim. With specialty drugs costing so much these days, these kinds of unjustified markups are too big to ignore.
Here’s why health plans should consider doing a pharmacy FWA audit:
Here are tips for health plans that conduct their own pharmacy FWA audits:
There are advantages to hiring an outside firm with pharmacy FWA audit experience:
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