Fraud, Waste and Abuse Program

Integrating established clinical strategies to identify, alert and intervene with aberrant, high-risk prescribing and dispensing patterns and therapeutic care for the injury, PMSI's Fraud, Waste and Abuse specialty program can resolve concerns and prevent potential incidents to reduce unnecessary risks and costs. The multi-faceted program concentrates on three communities of interest whose behaviors throughout the claim lifecycle can be analyzed for high-risk indicators:

  • Injured Workers
  • Physicians
  • Pharmacies

PMSI's Fraud, Waste and Abuse program evaluates at both the population and individual levels to identify high-risk behaviors within these communities of interest. PMSI's owned network of nearly 65,000 participating retail pharmacies nationwide maintains rigorous audit practices and point-of-sale safeguards that reduce potential instances of fraud, waste and abuse at the pharmacy level.

The Population Risk Scorecard predicts risk within the injured worker population from the perspective of medication use. Applying a proprietary set of criteria to prescription claims, clients can focus on the segment of the claimant population exhibiting utilization behaviors inconsistent with best-practice clinical guidelines and evidence-based medicine.

The Prescriber Profiling Report identifies prescribing behaviors outside normal parameters identified as high-risk. Clients receive a custom report listing any prescribers exhibiting high-risk behavior associated with claims in the payor's population. A list of indicators on which the high-risk classification is based and claimant/transactional data for the associated claims is included in the report. As part of the Population Risk Scorecard and the Prescriber Profiling Report, PMSI provides recommendations on available intervention options to resolve the issues to mitigate risk and ensure positive health outcomes for injured workers.

Using the capabilities of the MedAssess Risk ISTM, all transactions are analyzed through a multi-dimensional model that recognizes key indicators to trigger alerts, recommends interventions, and continuously monitors injured workers, physicians and pharmacies exhibiting behaviors potentially related to fraud, waste or abuse scenarios.

  • High-Risk Profiling - Flags irregular behavior involving narcotic prescribing and utilization within the physician and injured worker communities
  • Medication Reviews and Peer-to-Peer Outreach - Evaluates the appropriateness of prescribed therapy for the injury, which may require a peer-to-peer review
  • Drug Testing and Monitoring - Assesses the proper use of prescribed medication and detects the presence of any illegal drugs
  • Generic Conversion - Identifies when brand-to-generic conversion is not utilized
  • Multiple Prescriber Outreach - Converts multiple prescribers of narcotics to one lead prescriber
  • Clinical Escalation Alerts - Triggers alerts when transactions meet pre-defined clinical criteria specific to narcotics


    Five Phase Approach to Fraud, Waste and Abuse

    Identify Alert Act Monitor
    Early identification of behaviors that may be indicative of potential fraud, waste and abuse including:
    • Excessive or inappropriate use of opioids
    • Early refills of controlled substances
    • Brand utilization when generics are available
    • Use of multiple pharmacies
    • Use of multiple prescribers
    • Excessive physician-dispensed medications
    • Excessive dispense-as-written prescriptions
    • Legal sanction/censure records
    Clients receive alert notifications to ensure awareness and opportunity for further investigation. These notifications are provided in a variety of methods including:
    • Clinical Escalation Alerts via VitalPointTM
    • Medication Review recommendation reports
    • Drug Testing and Monitoring recommendation reports
    • Prescriber Profiling Report
    Based on the type of notification and behavior identified, clients have a variety of options for intervening on targeted activities. PMSI can facilitate many of these actions including:
    • Utilization Review
    • Medication Review
    • Peer-to-Peer Outreach
    • Referral to Case Management
    • Multiple Prescriber Outreach
    • Hard blocks on selected medications during adjudication
    • Hard blocks on selected physicians during adjudication
    PMSI provides ongoing monitoring and updates for actions and interventions performed at the client's request:
    • Peer-to-Peer Outreach follow up and progress reporting
    • Drug Testing and Monitoring service
    • Multiple Prescriber Outreach follow up
    • Quarterly Business Reviews including Population Risk Analysis
    PMSI provides educational information to increase awareness about current issues, new developments and methods for prevention and management of fraud, waste and abuse including: