The City of Fort Worth, Texas — the 12th largest city in the U.S. and the 5th largest in the state — presents a textbook case study for the pervasiveness of pharmacy fraud hidden in health care claims and the action required to combat the ever-evolving abuse.
Analysis of health care claims from a sampling across multiple employers with self-funded health care plans and a combined total of more than 100,000 members, identified over $25 million in fraud, waste, and abuse by providers. The assessments found claim errors, pharmacy fraud and member issues, however, across every employer’s data, provider fraud accounted for the highest amount of wasted dollar.
Examining exactly where health care dollars are spent is not just a budget management or cost-saving practice for business, as plan sponsors are reminded often, it is also a fiduciary responsibility under the Employee Retirement Income Security Act (ERISA).
