What is Prescription Fraud and Abuse?

Engaging in prescription fraud is when someone knowingly uses false information, statements or misrepresentations to obtain prescription drugs or payment for prescription drugs when the person is not entitlement to the drugs or payment.

Some examples of prescription drug fraud are:

  • A pharmacy submitting claims for medications that the patient never received;
  • A patient or other person forging or altering a prescription;
  • A person obtaining prescriptions for drugs in order to sell them;
  • A physician writing a prescription for drugs for someone that is not a patient because the physician receives a kickback payment; or
  • A member selling their medical ID card or prescription to someone.  

Prescription Abuse includes actions that may result in unnecessary costs such as requesting payment or filling prescriptions for drugs when there is not a legal entitlement. Some examples include:

  • Using another person’s insurance coverage or insurance card, or letting someone use your insurance card because they don’t have insurance;
  • A pharmacy billing for brand medication, when it dispensed a generic medication;
  • Person falsely stating drugs were lost or stolen and requesting replacement drugs because of addiction problems.

Who does Prescription Fraud and Abuse Affect? 

The answer is everyone, which is why Navitus Health Solutions (Navitus) is committed to ensuring it maintains a robust fraud, waste and abuse program.

How does Navitus Help Prevent and Detect Fraud, Waste, and Abuse?

Navitus Health Solution’s Special Investigations Unit (SIU) is responsible for protecting the assets of its clients and reducing the overall cost of prescription drugs by preventing, detecting, and investigating fraud, waste, and abuse.  Navitus’ certified and licensed professionals investigate all referrals from both internal and external sources.  The SIU professionals also stay abreast of the latest fraud schemes and partner with pharmacies and clients on identifying potential fraud and abuse using a convenient reporting system.

What Can You Do?

To report possible FWA please email, call the confidential reporting hotline at 855-673-6503, or send a letter to Navitus’ Chief Compliance Officer at the address below. Reports can be made anonymously if desired.

Attention: Debbie Ludka
Senior Vice President, Customer Operations & Chief Compliance Officer
1025 West Navitus Drive
Appleton, WI 54913

Navitus will make every attempt to maintain confidentiality, but that confidentiality may not be guaranteed if law enforcement becomes involved. Navitus has a strict non-retaliation and non-retribution policy for FWA reports made in good faith.

The Navitus FWA program complies with CMS requirements for effective communication set forth in 42 C.F.R. §§422.503(b)(4)(vi)(D), 423.504(b)(4)(vi)(D).