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PHARMA INDUSTRY RISK FACTORS
Retail Pharmacy Risk Factors
- Drug diversion schemes using Client's Members to
balance narcotic counts
- Fraudulent submission of claims for payment (False claims submission)
- Billing for higher priced generic than what is dispensed
- Dispensing illegally imported or outdated drugs
- Not reversing errors or prescriptions returned to stock
- Collusion between Beneficiaries, Physicians, Nurse Practitioners
& Criminal Entities
- Split prescription to obtain multiple fees
- Dispensing Unauthorized refills, Illegal drug substitution
- Pricing spreads between Client & pharmacy
- Zero cost prescriptions
- Allowing payment of claims with invalid prescriber
- Pay pharmacy using lower pricing source to create spread
- Pay pharmacies to switch to PBM preferred drug
- Up to triple payment of admin fee on reversed claims
- Payment spread on professional fees
- Allow inflated pricing from re-packagers
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