Prime Therapeutics LLC saw telemedicine schemes contribute to a 60% year-over-year increase in reported false claims from 2020 to 2021. The Blue Cross Blue Shield affiliate-owned PBM, which is in its second full year of an artificial intelligence-powered fraud, waste and abuse (FWA) reduction program, reported that the program saved its health plan clients $285 million in 2020, in part because it detected telemedicine-driven schemes.
Elan Rubinstein, Pharm.D., head of pharmacy benefits consulting firm EB Rubinstein Associates, says it’s unsurprising that increased telemedicine led to a spike in prescription fraud.
“Because telemedicine is relatively new and it grew very quickly during the pandemic, it seems a good target for fraud and abuse,” he tells AIS Health, a division of MMIT. “A traditional patient-physician encounter is in-person and based on a relationship, and the patient most commonly would take a resulting prescription to a local pharmacy that may have the patient and the prescriber on record. In contrast, a telemedicine encounter may be between strangers, not necessarily in the same state, who may never meet again. A medicine e-prescribed by a telemedicine physician would be transmitted to a patient’s local pharmacy, where both the pharmacist and the pharmacy computer system are unlikely to recognize the prescriber.”
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