Fraud, Waste and Abuse
Navitus Confidential Reporting Hotline: 855-673-6503
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 entitled 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;
- Theft or unauthorized use of a member's medical identification; 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 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' 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, vendors and clients on identifying potential fraud and abuse using a convenient reporting system.
If you or one of your employees suspect fraud, waste or abuse, please report this activity using the form accesible in Quick Links below, or by calling the Navitus Hotline at 855-673-6503. Navitus has a strict non-retaliation and non-retribution policy and expects all vendors to adhere to non-retaliation for reports made in good-faith.