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magnifying glass focuses on word fraud in red on balance sheet with calculator nearby PBMs can identify opportunities to recover claims, provide education or apply controls to prevent financial loss, improve safety and support claims integrity. (Photo: Shutterstock)

The National Health Care Anti-Fraud Association estimates that the U.S. health care system loses tens of billions of dollars every year to fraud, waste and abuse (FWA). A large portion of these costs are attributed to pharmacy spend, including duplicate claims, data entry errors, forged prescriptions and intentional overcharging.

Pharmacy FWA can result in misused benefits, safety issues among plan members and unnecessary financial losses for employers and plan members. Even more, policy and regulation changes during the pandemic, such as expanded access to telehealth and waived prescription refill limits, have created new avenues for fraudulent activity. So how can plan sponsors protect their members from these risks?

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