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The $80+ Billion Price Tag of Healthcare Fraud

  • Feb 25, 2022
  • PBM Model
Each year, healthcare fraud and abuse drains off tens of billions of dollars that might have gone to lower medical insurance premiums and expanded prevention and treatment services for patients. Although countering these schemes can be difficult, data mining and other interventions may help to defray at least some of the damage, experts noted during a recent webinar.

One reason why anti-fraud measures can be a huge challenge is the fast-paced nature of pharmacy claims processing, said Carrie Aiken, CHC, the vice president and corporate compliance and privacy officer at Navitus Health Solutions, a Pharmacy Benefit Manager (PBM) owned jointly by SSM Health and Costco Wholesale Corp., and the sponsor of the webinar. “Pharmacy services are processed in real time,” Ms. Aiken explained. “That makes fraud, waste and abuse in the pharmacy space a crime of opportunity because it’s rapid. As a result, it requires rapid intervention to make sure we’re protecting those dollars for our plan sponsors and protecting beneficiaries.”

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