INFOGRAPHIC: Prescription Drug Fraud & Abuse

Aug 20, 2014
Prescription-drug fraud and abuse is deadlier than heroin and cocaine. Express Scripts is countering with detective work and industry-leading technology.

Americas Other Drug Problem

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In the United States, prescription drug overdoses kill more than 15,000 people and result in 1.2 million emergency room visits each year. Abuse of these medications is deadlier than cocaine and heroin combined.

Many of these abused drugs are obtained fraudulently. Individuals obtaining prescription drugs illegally to support an addiction, phantom pharmacies, pill mills and forged prescriptions all take a toll. Even organized crime has added pharmacy fraud to its umbrella of illegitimate business fronts.

Everyone pays for prescription drug fraud – in premiums, healthcare costs, benefit costs and taxes. So what is Express Scripts doing to end this epidemic?

The problem of prescription drug fraud and abuse affects more than just the pharmacy benefit. When abused drugs are obtained through "doctor shopping," a significantly larger amount of money is wasted on unnecessary doctor visits and tests. In fact, for each dollar spent on potentially abused drugs, an additional $41 is spent on associated medical claims.

In total, between 3% and 10% of every healthcare dollar spent in the U.S. is lost to fraud. That equals as much as $224 billion each year – a heavy burden for the nation's healthcare system.

The Express Scripts Fraud, Waste & Abuse Team

It's a complex, ever-changing challenge. At Express Scripts, the fight against prescription-drug fraud and abuse involves a combination of tried-and-true detective work and state-of-the-art technology. The Express Scripts Fraud, Waste & Abuse team uses industry-leading, proprietary data analytics to uncover patterns of potential fraud or abuse, and scans for behavioral red flags to identify when someone is involved in wrongdoing.

By combining the complementary capabilities of Express Scripts’ unique platform, Health Decision Science℠ – behavioral sciences, clinical specialization and actionable data – the team has identified 290 potential indicators of pharmacy fraud.

The team receives thousands of tips each year, follows up on hundreds of cases and, in 2012 alone, identified and referred more than 500 cases of potential fraud to clients and law enforcement agencies. With every case, our expertise grows, and the data identification and analysis become more robust.

Collaborating with clients, government agencies and law enforcement is a key component of the team’s work.

Plan sponsors rely on these efforts to help keep their pharmacy networks safe and affordable and to ensure healthier outcomes for their members.

The fight to end prescription-drug fraud and abuse is complex and ever-changing, but it's a fight worth fighting.

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