Fraud Waste & Abuse Management

fraudmgtCMS Fraud, Waste & Abuse Reporting

All plans should be collecting and managing these data as essential ingredients of policies and procedures.

If there is evidence of FWA, and appropriate policies and actions are not implemented, there is the potential for CMS sanctions and civil monetary penalties.

Member-based reports:

  • Top 25 Members by Plan Paid
  • Top 25 Members by Utilization
  • Top 25 Members by quarterly changes in utilization
  • Controlled Substance Activity: Members above “normal range” for CSA, utilizing multiple prescribers, multiple pharmacies, out-of-area pharmacies, and “overlap” prescriptions
  • Controlled Substances – High quantity claims
  • Duplicate therapeutic class scripts

Prescriber-based reports:

  • Top 25 Prescribers by Plan Paid
  • Top 25 Prescribers by Utilization
  • Top 25 Prescribers by quarterly changes in utilization
  • Top 25 Prescribers by DAW prescriptions
  • Top 25 Prescribers by % of brand prescriptions

Pharmacy-based reports:

  • Top 25 Pharmacies by Plan Paid
  • Top 25 Pharmacies by Utilization
  • Top 25 Pharmacies by quarterly changes in utilization
  • Pharmacies submitting multiple claims for “low days supply” within 30 day periods
  • High Dollar Claims: Pharmacies that exceed >$500 total paid
  • Pharmacies exceeding the “normal range” for DAW claims

Watch List reports:

  • Top 25 Members by Plan Paid (county watch list)
  • Top 25 Members by Utilization (county watch list)
  • Top 25 Prescribers by Plan Paid (in watch list counties)
  • Top 25 Prescribers by Utilization (in watch list counties)
  • Top 25 Pharmacies by Plan Paid (in watch list counties)
  • Top 25 Pharmacies by Utilization (in watch list counties)

PrescienceRx  reports on all the above factors which go beyond the CMS regulations, but are crucial for the management of your Part D program and care management.

Contact Aligncare

© copyright 2015-2017 Aligncare.comSite Design