Electronic Prescription Fraud

Most community pharmacy employees know the “red flags” to spot a fraudulent written prescription such as it “looks too good”, has irregular quantities and instructions, different color ink or handwriting, and doesn’t follow the typical medical shorthand.

Unfortunately, it is much harder to spot a fraudulent electronic prescription. The bad guys are now using sophisticated computer schemes to steal login credentials from prescribers and hijack electronic health record systems to initiate thousands of fraudulent e-prescriptions to pharmacies across the country within a short period of time. When these e-prescriptions are received at the pharmacy, the normal red flags are nowhere to be seen, and they may slip through undetected.

For these fraud schemes to pay off, the criminals must actually get their hands on the medications. Target medications are often not just controlled substances that can be sold on the street, but also expensive branded medications (dispensed in manufacturer stock bottles) that can be recirculated through an illegitimate supply chain. A Drug Topics article from April 2024 outlined these schemes including the use of “drug runners” to pick up medications from unsuspecting pharmacies.

Pharmacies need to be aware that the end-to-end electronic prescribing process, while generally secure, does have the potential to be exploited by criminals. It is important that both pharmacy technicians and pharmacists play a role to protect the integrity of this process. Pharmacies should consider some basic strategies to determine authenticity of e-prescriptions to ensure your pharmacy isn’t pulled unwittingly into a fraud scheme.

Below are some techniques to spot fraudulent electronic prescriptions at your pharmacy:

Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!

Join today!

  1. Know the prescriber
    1. Is this a new prescriber in your area?
    2. Have you received electronic prescriptions from this prescriber before?
    3. Is the medication within their scope of practice?
    4. Can you verify prescriber information (e.g. phone, address) through public resources?
    5. Check your state PDMP for any controlled substance prescriptions that don’t add up.
  2. Know the patient/caregiver
    1. Is this a new patient at your pharmacy?
    2. Does this patient live within your service area?
    3. How did you obtain the third-party billing information?
    4. Consider requiring a copy of photo identification for prescriptions picked up for new patients
    5. Large cash copays paid by a representative unknown to pharmacy may be a clue that they are trying to avoid detection
    6. Some level of skepticism, if all interactions are with a personal representative
  3. Review the prescription for unusual items such as:
    1. Is dose regimen outside the norm?
    2. Does patient have indication to support use?
    3. Does the patient have other prescriptions from this prescriber? Can the patient confirm they are being treated by the prescriber?
    4. Are there multiple prescriptions issued for high-cost medications brand medications, particularly those that may be dispensed in their original, intact containers?

With fraudulent electronic prescriptions being on the rise, pharmacies should consider formulating a business policy to handle these situations. A key first step is conducting due diligence before concluding that a prescription is fraudulent. When validating with a prescriber, the pharmacy should request documentation [preferably in writing] that the prescription is fraudulent. If the prescription was billed to insurance and later reversed due to a determination of it being a fraudulent prescription, the hardcopy should still be retained in case of an audit. The prescriber should take the lead on notifying authorities and researching their stolen credentials, but pharmacies may have a corresponding responsibility to notify the state board of pharmacy and/or DEA (especially when prescriptions were dispensed). FWAC Members can utilize the custom content section of their Policy and Procedure Manual to create and upload a fraudulent prescription policy.

If a prescription is dispensed and later identified as fraudulent, pharmacies are obligated to reverse the claims and likely notify the third-party payor. During a PBM audit, fraudulent electronic prescriptions will be subject to financial recoupment and the onus will be on the pharmacy to prove that they were ‘duped’ as well and not in on the fraudulent activity.

PAAS Tips:

  • DEA has a brief video about fraudulent e-prescriptions and a handout on general prescription fraud here
  • When prescriptions are identified as fraudulent, document your due diligence efforts on the prescription or in your pharmacy management software

Eric Hartkopf, PharmD
Latest posts by Eric Hartkopf, PharmD (see all)