The booming demand for GLP-1 receptor agonists such as Ozempic, Wegovy, and Mounjaro, used for weight loss and Type 2 diabetes, has sparked a surge in fraudulent activity across Medicare, Medicaid, and commercial insurance. From inappropriate prescribing and billing anomalies to falsified diagnoses, payers are confronting an emerging fraud scheme that demands both advanced data analytics and effective investigative strategies.
Fraud Schemes Involving GLP-1 Drugs
GLP-1 fraud is evolving rapidly with schemes such as:
- Off label prescribing and billing for non-covered indications like general weight loss.
- Falsifying diagnoses, for example, coding obesity or diabetes without supporting documentation.
- Prescription mills where providers issue high volumes of GLP-1 prescriptions without adequate patient evaluations.
- Kickback arrangements between prescribers and pharmacies or telehealth platforms.
- Compound pharmacy manipulation, where ingredients are substituted to mimic GLP-1s while bypassing regulations.
These types of schemes capitalize on potential gaps in oversight of telemedicine, prior authorization vulnerabilities, and inconsistent payer policies.
Leveraging Data Analytics in GLP-1 Fraud Detection
A data driven approach is essential to identifying and prioritizing high risk providers and patterns. Key analytics strategies may include:
- Outlier analysis: Compare GLP-1 prescription rates per provider against geographic, specialty, and peer group norms.
- Trend detection: Identify spikes in prescribing volume following FDA approvals or formulary changes.
- Cross claim correlation: Check for consistency between GLP-1 prescriptions and corroborating diagnoses such as A1C lab values or BMI.
- Telehealth risk scoring: Flag virtual only providers with high GLP-1 prescribing and low documented encounters.
Investigative Approaches to GLP-1 Fraud
An integrated, investigative approach helps connect the data patterns and billing or prescribing behavior, turning red flags into actionable evidence. Investigations may follow a multi-pronged path to uncover intent and validate fraud indicators, using tactics such as:
- Provider Review: Examine prescribing history, sanctions, and known ties to flagged pharmacies or telehealth platforms.
- Beneficiary Interviews: Confirm whether services and prescriptions were actually received—often revealing issues not seen in claims or charts.
- Prescriber Interviews: Understand clinical rationale and detect inconsistencies in justification.
- Pharmacy Mapping: Identify repeat patterns or networks between prescribers and dispensing locations.
- Documentation Review: Look for cloned or templated notes, inconsistent records, or inconsistency in diagnosis or billing codes.
Integrating Medical Review into Investigative Strategy
In Medicaid, where coverage for GLP-1s varies by state, medical reviews also help assess whether prescriptions align with policy specific coverage criteria such as prior authorization approvals, BMI thresholds, or failed alternative therapies. While analytics can triage risk, targeted medical record review is essential for validating fraud hypotheses.
For example:
- Diagnosis substantiation: Does the chart support a diagnosis of Type 2 diabetes or obesity?
- Clinical rationale: Is there documentation of lifestyle interventions or medication justification prior to prescribing GLP-1s?
- Treatment history: Are there attempts at step therapy before initiating a high-cost drug?
Collaborative Oversight is Key
At IntegrityM, we specialize in helping payers detect and prevent healthcare fraud. Our team leverages advanced data analytics to identify suspicious patterns, conduct targeted investigations, and validate findings through expert medical review. These integrated capabilities protect healthcare dollars and ensure access to care for beneficiaries/members.
Whether you’re battling rising GLP-1 costs, uncovering complex billing schemes, or struggling with provider oversight, IntegrityM is here to help you take control. Our team transforms insights into action, so you can protect your program, your beneficiaries/members, and your healthcare dollar expenditure.
