Prescription medications make up about 7% of the costs of a workers’ compensation claim in the United States.1 Most of these prescriptions are filled without issue and follow all the appropriate pricing and dispensing rules. Mixed in there however might be instances when:
- A pharmacy dispensed a high-priced medication NDC when lower-cost NDC options were available.
- A physician dispensed Lidocaine 4% patches at a much higher volume than local peers.
- A patient filled multiple prescriptions from multiple doctors at multiple pharmacies.
- A pharmacy re-submits denied bills after altering information (e.g., prescriber)
While these cases may be infrequent, they could be fraud, and fraud can lead to higher costs, medication misuse, and even legal prosecution.
“On behalf of our clients, we work with pharmacies, providers, and injured workers to make sure injury-related prescriptions are dispensed at the right time, to the right person and at the appropriate cost,” said Brandie Traylor, Vice President of Product Management for MyMatrixx by Evernorth.
This means a series of processes to check eligibility, clinical appropriateness, fee schedules, formularies, state and federal guidelines, and customized edits. With all that, the anomalies−whether purposefully or by accident−sometimes make their way into pharmacy transactions.
“At first glance, payers may never know that fraud is taking place. The prescriptions are processing, and injured workers are getting their medications, but they are losing money. If they don’t know about the fraud, they can’t fix it,” continues Traylor.
This is where MyMatrixx can help.
"The MyMatrixx Enhanced Fraud, Waste, and Abuse program is a smart addition to a pharmacy program,” added Cliff Belliveau, MyMatrixx Chief Innovation Officer. As a leader in the workers’ compensation industry, the MyMatrixx FWA program is designed specifically for the nuances of workers’ compensation claims and transactions.
The foundation of our program is a proprietary algorithm, which analyzes injured worker, prescriber, pharmacy, and historical claim data to identify actions such as drug seeking, duplication of therapy, and abnormal prescribing and distribution patterns.
“You can learn a lot by deep mining prescriber, pharmacy and patient data,” states Belliveau. “Applying these well curated data algorithms gives us a closer look at a payer’s book of business and the potential fraudulent trends within it,” he continued.
“Once we identify the potential fraud, we can take action to change the behaviors,” said Traylor. We investigate the issue and the submit, track, monitor and share information related to the potential fraud.
“This is a detailed process that can make a big difference to our clients,” stresses Traylor. With a recent client, MyMatrixx identified a series of fraudulent medication charges that, once corrected, could save the client over $500,000.
Cases of fraud are in workers’ compensation claims, but don’t fear them. Be ready for them. The MyMatrixx Enhanced FWA program can help you find them and fix them.
For more information about the MyMatrixx Enhanced FWA program, email info@mymatrixx.com.
1. https://www.ncci.com/SecureDocuments/AES_Content/Medical_Dilemma_Rx.html