Case Study: Northeastern Coalitional Finds FWA Despite PBM Assurances Methods? Problem: A large coalition of union funds in the Northeastern did not realize that fraud, waste and abuse (FWA) was occurring. The Coalition’s pharmacy benefit manager (PBM) had assured coalition and union fund management that it was one of the most sophisticated PBMs in monitoring FWA and “all was being taken care of” with regard to monitoring FWA in the retail pharmacy network. In fact, the PBM reported significant savings due to FWA auditing. Yet, claim costs continue to rise with no apparent reason. Solution: PIC loaded two weeks’ of claims into the COPs system. The system almost immediately spotted a cluster where almost all of one physician’s claims were being directed to a large chain

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