The session will cover two drug categories and medications commonly used and current trends of fraud, waste and abuse. The four medications include GLP-1 (Ozempic/Mounjaro) and Antivirals combinations (Descovy & Biktarvy). Each drug will cover its directed use by manufacturers and common side effects, this will segue into issues of patient harm being inappropriately prescribed and its financial impact on health plans. Data analytic tactics using patient historical clinical indications to identify potential FWA providers/members and approaches to address outliers. The aftermath of inappropriately prescribing causing pharmacy inventory shortages, diversion, misbranding and counterfeit production by fraudsters for profit.

Learning Objectives:

1) Identifying counterfeit medications mentioned in presentation.

2) Implementation of provider education, recoveries and cost-saving best practices

CEU Eligibility: COC, CPC, CPC-P, CPB, CPPM

In the ever-evolving landscape of healthcare, balancing cost containment with maintaining strong provider relationships is a critical challenge. This session will explore effective strategies to control costs while fostering positive, collaborative relationships with providers. Attendees will gain insights into practical approaches and best practices that align financial objectives with the goal of delivering high-quality patient care.

Learning Objectives:

-             Collaborative Approaches to Payment Integrity

-             Efficient Billing and Coding Practices

-             Provider Education and Training

-             Monitoring and Continuous Improvement