Fraud, waste, and abuse
Protect members and control costs with integrated fraud and safety solutions. CVS Caremark offers clients a single integrated approach to address fraud, waste, and abuse (FWA) at the member, prescriber, pharmacy, and drug levels, including integrated reporting and ongoing enhancements.
Losses from uncontrolled fraud, waste, and abuse (FWA) can be significant.
Up to 10% of health care spend can be wasted due to uncontrolled FWA1
Our integrated Fraud and Safety solutions augment your existing FWA programs with multiple elements that work together to help protect your pharmacy spend:
- Surveillance scanning for high-cost hyperinflated drugs and new to the market
- Proactive measures through formulary and utilization management
- Identification and intervention to identify higher-risk members on factors such as multiple pharmacies or excessive utilization, resulting in prescriber outreach
- Regular network reviews and collaboration with regulatory agencies where appropriate
- Investigation and case management
- Research and course of action, including pharmacy follow-ups and prescriber consultations
$27.66 PMPY client savings6
Case study
Savings through pharmacy surveillance
A multinational auto manufacturer needed to meet ambitious savings targets while still providing robust pharmacy benefits. Ongoing pharmacy surveillance by CVS Caremark allowed the client to meet their goal.
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CVS Caremark.
Employer Case Study: Savings through pharmacy surveillance.
Situation.
A multinational automotive manufacturer needed to meet ambitious pharmacy savings goals, while still providing robust pharmacy benefits to 135,000 union and non-union members.
Solution.
Ongoing, real-time claim and pharmacy surveillance.
Identified aberrant dispensing of high-cost, low-value products.
Substituted lower cost, clinically equivalent alternatives.
Results.
Monthly spend on low-value drugs decreased from $170,000 to less than $20,000.
Annual savings of $1.8 million.
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1 www.nhcaa.org/resources/ health-care-anti-fraud-resources/the-challenge-of-health-care-fraud
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2 P1012660822
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3 P1009951021
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4 P1011020122
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5 P1011010122
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6 P1012660822
