Lipitor Fraud and Waste

Lipitor Fraud and Waste

Healthcare Fraud Control Articles

The cholesterol lowering drug, Lipitor, is an expensive maintenance drug taken by a large percent of the adult population. Most people who take Lipitor have no symptoms. A cholesterol test showed that they have high cholesterol, so they get the prescription.
Once prescribed, patients will take this drug until something new replaces it. These factors make it the perfect drug for a pharmaceutical company’s bottom line. They also make it a target for fraud.

There are two kinds of fraud and abuse common to Lipitor: diversion and over-prescribing.

Diversion

Because we don’t have universal healthcare coverage in the US, each person who takes Lipitor pays a different amount. Some people pay nothing, while others pay the full cost, and most pay something in between.

Medicaid recipients have the greatest incentive to sell their Lipitor. The Lipitor is free, and they could use the cash. Because they have no symptoms, the need for cash seems more urgent than the need for the drug. The drugs can then be sold at a discount pharmacy online or sold to an unscrupulous wholesaler.

Identifying this diversion is difficult. The patient may meet all the criteria for receiving the drug. How can you tell that they sold it? The best possibility is to work with the DEA. Together, you’ll have to find the dealers first, then tie that to healthcare fraud through identifying the suppliers and who paid for the medication.

Waste

Chances are you are spending a huge amount on Lipitor. Some of that spending may not be warranted, but how can you find out?

According to the American Heart Association, “240 mg/dL or higher are considered high, and levels from 200 to 239 mg/dL are considered borderline-high.” About half of all adults in the US have borderline-high or higher cholesterol, and about 20% have high cholesterol. American Heart Association

How high should cholesterol be before medication is warranted? What other risk factors should be present? How would you know whether the medication is needed? Unfortunately, claims data does not include the information that allows you to tell whether an individual prescription was justified. However, you can use provider profiling and link analysis to determine prescription patterns that seem unwarranted. You can create guidelines for cholesterol testing and treatment to help limit waste.