Pharmacy Fraud Within Pharmaceutical Co-Pay Programs: What You Need to Know

On a single day in early January 2019, Mercalis' (formerly TrialCard) Incorporated’s Pharmacy Fraud Detection team identified and blocked three pharmacies engaged in fraudulent behavior associated with pharmaceutical co-pay programs. These pharmacies submitted claims for payment on expensive prescriptions that were never filled or distributed to patients.

Fortunately, Mercalis (formerly TrialCard) was able to intercept the fraudulent transactions on the same day they were submitted, thereby saving our client nearly $2 million. Had these claims gone through, the brand’s reimbursement budget for the entire year would have been exhausted.

These are not isolated incidents. Mercalis (formerly TrialCard) discovers an average of five fraudulent pharmacies per month. The dollar amount associated with this fraudulent behavior can be staggering, especially when you consider that in many cases, smaller pharmacies are committing these criminal acts.

As a pharmaceutical solutions provider, Mercalis (formerly TrialCard) partners with brands in order to help patients obtain—and remain on—potentially lifesaving therapy. As such, we are accustomed to having difficult conversations with our pharmaceutical manufacturer clients about risk mitigation and compliance challenges they face. The issue of pharmacy fraud is especially personal for us; we want to ensure that our client’s dollars assist consumers in need, not line the pockets of rogue pharmacy owners whose behavior is completely contrary to the benefit of the patients that they have promised to serve.

When Mercalis (formerly TrialCard) identifies a pharmacy that is involved in unscrupulous behavior, we immediately remove the pharmacy from our network. The pharmacy in question is also permanently blocked from participating in all future programs. As a result, any legitimate patients seeking to fill prescriptions at the offending pharmacy will not be able to use our co-pay cards, possibly paying more for their medications or abandoning therapy altogether.

In an effort to continuously improve our service offerings to clients, Mercalis (formerly TrialCard) recently completed additional enhancements to its Pharmacy Fraud Detection capabilities. While we were very adept at detecting fraud in the past, we knew there was a need to re-tool our product to keep pace with the changes we had recently observed in the market. Our solution also had to discover a way to stop the flow of reimbursement cash to the offending pharmacies.

Mercalis' (formerly TrialCard) dedicated product manager, working with an in-house analytics team, developed a comprehensive proprietary algorithm that helps to reveal the offending pharmacies–and does so in less time. The Mercalis experts, with backgrounds in federal law enforcement, were able to view the problem—and solution—through a different lens. Mercalis (formerly TrialCard) also identified a need for a full-time, dedicated fraud investigator and hired an expert with more than a decade of experience at one of the nation’s largest insurance companies.

The result? Spotlight®—Mercalis' (formerly TrialCard)s new, industry-leading pharmacy fraud detection tool. Spotlight examines all pharmacy claims in near real time and flags pharmacies that are potentially engaging in fraudulent behavior.

Due to the high number of patient affordability programs that Mercalis (formerly TrialCard) manages, we are able to cross-reference multiple data points to spot anomalies. By utilizing this plethora of data, we are able to flag suspect pharmacies and stop many pharmacies from receiving payment for fraudulent claims. In January 2019 alone, Mercalis (formerly TrialCard) removed eleven pharmacies from our extensive network, thereby preventing millions of dollars from reaching the offending pharmacies.

With fraudulent pharmacy activity on the rise, it is crucial that pharmaceutical manufacturers choose a solutions provider like Mercalis (formerly TrialCard) who can quickly detect fraudulent pharmacy activity before payment is sent to the offending pharmacies. Once payment has been made, it is very difficult to recover. Although no solution is 100% effective, the enhancements made to Mercalis' (formerly TrialCard) fraud detection methodology and the addition of a full-time fraud investigator will further assist brands in reducing market risks.

For more information about Mercalis' (formerly TrialCard) pharmacy fraud detection product, please email us at sales@mercalis.com.