Beyond Fraud Detection: Transforming PBM Fraud, Waste, and Abuse Programs
Modern Pharmacy Benefit Manager (PBM) payment integrity programs not only recover improper payments but also prevent the negative clinical and financial impacts of fraud, waste, and abuse (FWA), while improving patient outcomes, preventing unnecessary healthcare spending, and strengthening patient safety.
Prescription drug FWA contributes significantly to rising healthcare costs and can expose individuals to preventable clinical and safety risks. In response, PBMs are strengthening payment integrity programs through proactive clinical oversight, prepayment controls, pharmacy network governance, and advanced analytics, shifting intervention upstream to identify and prevent inappropriate utilization and spending before they occur.
This analysis highlights how CarelonRx’s approach to FWA can improve medication safety, reduce unnecessary healthcare utilization, and help prevent medical complications associated with inappropriate medication use. As payers, policymakers, and other stakeholders focus on healthcare spending and value, integrated FWA programs should be recognized as foundational investments in clinical quality and accountability.
Related Public Policy Research
Executing Payment Integrity Through Medicaid Managed Care
Medicaid managed care organizations are well positioned to successfully prevent and recover improper spending of Medicaid funds. This paper outlines how Elevance Health’s payment integrity framework uses front-end controls, provider engagement, advanced analytics, specialized investigations, and government collaboration to prevent and detect improper payments.
Potential Medicare Savings on Select Services Subject to Fraud, Waste & Abuse
Traditional Medicare could have saved $7 billion from 2019-2023 on four services, which the HHS Office of the Inspector General identified as subject to fraud, waste, and abuse—skin substitutes, catheters, genetic testing, and off-the-shelf orthotic braces—if its utilization rates mirrored those of Medicare Advantage.
Pharmacy Benefit Manager Safety Measures for Opioids for Dental Pain
Anyone who takes prescription opioids to manage acute or chronic pain can develop opioid use disorder (OUD), a problematic pattern of opioid use that causes significant impairment or distress. Elevance Health’s CarelonRx pharmacy benefit manager (PBM) implemented a policy in 2020 that has successfully mitigated unnecessary and inappropriate prescribing of opioids for the treatment of dental pain.