A doctor writes the prescription. A pharmacy fills the prescription. A patient gets the prescription. This straightforward process takes place every day. In fact, The Centers for Medicare and Medicaid Services estimates that prescription drug spend in the United States will reach around $460 billion in 2024.1 Most of these prescriptions are filled without issue and follow all the appropriate pricing and dispensing rules.
Sometimes, though, rules are not followed:
+ A pharmacy dispenses a higher-priced medication NDC when lower-cost NDC options are available.
+ A physician dispenses lidocaine 4% patches at a much higher volume than local peers.
+ A patient fills multiple prescriptions from multiple doctors at multiple pharmacies.
+ A pharmacy re-submits denied bills after altering information (e.g., prescriber)
Whether purposefully or accidentally, these could be cases of medication fraud, waste or abuse (FWA), which can lead to higher costs, medication misuse and legal prosecution. And, while cases of FWA may be infrequent, the impact is substantial. The Pharmaceutical Care Management Association estimates that 1% of U.S. drug costs are attributable to fraud, waste and abuse.2 One percent of $460B is still billions of reasons why you should identify, stop and correct FWA. For individual payers, that means there are likely thousands or millions of reasons to have an FWA program monitoring their pharmacy claims.
Get access to our white paper to learn more about how MyMatrixx helps clients identify, stop and correct cases of fraud, waste and abuse that might be hiding in plain sight in your workers’ comp claims.
1. Prescription drug expenditure in the United States from 1960 to 2024; Statistica.com
2. Academy of Managed Care Pharmacy; Fraud, Waste, and Abuse in Prescription Drug Benefits