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A Costly Concern: The Fight Against Fraud, Waste and Abuse

November 15, 2018

The National Health Care Anti-Fraud Association estimates that tens of billions of dollars are lost to healthcare fraud, waste and abuse (FWA) each year. This includes all areas of healthcare, from medical to dental and pharmacy benefits. Prescription FWA can originate from patients, prescribers or pharmacies. It includes activities such as:

  • Unjustified billing of high quantities of medication and early refills
  • Pharmacies billing for drugs never dispensed to patients
  • Waiving copayments
  • Pharmacies billing for drugs not requested by patients
  • Patient drug seeking or doctor shopping

Fraudulent, wasteful and abusive actions unnecessarily increase costs for plan sponsors and force the raising of premiums and out-of-pocket expenses for patients. And in cases of identity thieves, hackers and online scammers accessing protected health information, plans can even incur fines and penalties.

Because healthcare FWA has become such a prevalent issue, the U.S. government developed the Medicare Strike Force, which brings together federal, state and local law enforcement to work together as a team to combat the issue. Every year the Medicare Strike Force takes enforcement action against individuals and organizations perpetrating FWA in the healthcare system. These actions, known as takedowns, led to charges against 412 individuals and organizations in 2017 and the largest enforcement efforts to date in June 2018, with more than 600 entities charged.[1]

A Strong Fraud-Fighting Team

The EnvisionRx Benefit Integrity department works to detect, prevent and address FWA affecting the prescription benefit, providing audit and investigative services designed to help protect our client’s financial and compliance interests and reputation.

This fraud-fighting team follows an aggressive program to stop fraud in its tracks. The EnvisionRx Benefit Integrity team identifies fraud risks early and promptly responds to referrals and complaints received through multiple channels. This is accomplished through:

  • Pharmacy Claims Audits – Verify claim billing accuracy in accordance with prescription records, and review prescriptions, signature logs, compounding, and shipping records
  • Special Investigations – Data mining of pharmacy patterns and identification of outliers, and investigations of pharmacies, patients, and prescribers
  • On-Site Audits – Auditor reviews prescription processing and recordkeeping at pharmacy, verifying compliance with state and federal regulations

Notable FWA-Fighting Efforts

Envision was recently recognized for our FWA-fighting efforts during a CMS and Medicare Drug Integrity Contract (MEDIC) FWA training seminar where we were mentioned for providing information that led to indictments in two successful cases:

  • In September 2013, we suspended a pharmacy after questionable findings from an invoice audit. Sharing these results with law enforcement led to the takedown of a $20 million Medicare Part D fraud scheme with multiple family members serving as co-conspirators.

  • In 2017, a Miami pharmacy owner was indicted for claiming to have dispensed drugs to Medicare beneficiaries that the pharmacy never even had in inventory. The fraudulent claims resulted in Medicare overpayments exceeding $1.1 million. Envision had suspended the pharmacy from our network one year earlier thanks to our fraud investigation efforts.

Thousands of audits are conducted every year. In 2017, several pharmacies were suspended from our network due to investigations and monitoring activities conducted by the Benefit Integrity team, resulting in millions of dollars recovered for our clients and numerous referrals to law enforcement and other external agencies. At the time of the 2017 Medicare Strike Force takedown, 71% of the involved pharmacies were already inactive in our network due to our diligent efforts to fight FWA.

While the fraud schemes and trends continue to evolve so do our methodologies. EnvisionRx will continue to strengthen our FWA-fighting efforts to protect our clients and their members.


[1] Office of Inspector General (2018). 2018 National Health Care Fraud Takedown.


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