The OIG conducted an inspection to determine the program integrity activities pharmacy benefit managers (PBM) use to detect fraud, waste, and abuse of Medicaid-funded prescriptions.
The two PBMs selected by OIG rely on three program integrity activities to detect FWA in overbilling, unauthorized refills, and unauthorized drug substitutions in Medicaid-funded prescriptions. The three program integrity activities are: a.) Edit Checks of Submitted Prescription Claims, b.) Daily Prepayment Review of Covered Prescription Claims, and c.) Audit of Paid Prescription Claims.