Health Care Fraud Schemes: Pharmacy
Fraudulent ePAs Reap Millions for Unscrupulous Pharmacy Owners
*Registration opens September 1, 2026.
Electronic prior authorizations (ePAs) can streamline access to medications—but they can also create opportunities for fraud when vulnerabilities in the process are exploited. In this case-study-driven training, investigators from Independence Blue Cross (IBX) examine a multimillion-dollar pharmacy fraud scheme involving falsified ePAs, high-cost medications, related pharmacies, prescription transfers, and questionable relationships among pharmacy owners, employees, and members.
Follow the investigation from the initial identification of unusual pharmacy utilization through the review of ePA accounts, prior authorization case files, medical records, pharmacy audits, and provider and member interviews. See how investigators connected red flags including spikes in high-cost medications, identical clinical documentation across unrelated patients and prescribers, questionable ePA account information, and connections among pharmacies, prescribers, and members.
The speakers conclude with the actions taken to mitigate the fraud, including reversing claims associated with falsified prior authorizations, suspending and terminating pharmacies, strengthening fraud review of PAs, addressing vulnerabilities in the ePA submission process, and referring the case to law enforcement. Throughout the case, see how collaboration among Payment Integrity, SIU, Pharmacy Services, the PBM, Legal, and law enforcement helped investigators turn individual red flags into a broader fraud investigation.
Learning Objectives
- Identify pharmacy claims, prior authorization, and ePA account red flags that may indicate fraudulent activity.
- Apply investigative techniques—including medical record review, provider and member interviews, pharmacy audits, and open-source research—to evaluate suspected ePA and pharmacy fraud.
- Evaluate relationships among pharmacies, prescribers, members, employees, and prescription transfers to identify connections that may support a broader fraud scheme.
- Describe mitigation and collaboration strategies that can help health plans address fraudulent prior authorizations and associated pharmacy claims
Speakers
Cindy McCutcheon
Senior Financial Investigator
Independence Blue Cross
Dana Mertz, AHFI, CPhT
Manager, Payment Integrity
Independence Blue Cross
Disclaimer: This monthly on-demand webinar was previously presented at the 2025 Annual Training Conference and 2026 Schemes for Health Care Fraud Investigators & Analysts
Registration Information
Employees of NHCAA Member Organizations, Government Liaisons, Supporting Members, and Individual Members can register online for NHCAA Monthly On-Demand trainings. A registration form is not available, you must login as a member to register. If you are having issues logging in or registering, please contact training@nhcaa.org.
Non-members, including local, state, and federal public agencies who are not NHCAA Government Liaisons, do not have access to NHCAA Monthly On-Demand trainings.
REGISTRATION RATES
| September 1-30, 2026 | After September 30, 2026 | |
| NHCAA Member Organizations1 | Complimentary | Complimentary |
| NHCAA Government Liaisons2 | Complimentary | $50 |
| Individual Members3 | $50 | $50 |
REGISTRATION POLICIES
Complimentary registration closes on the last day of the month. Paid registration is open after the complimentary time-period ends. The registration period for complimentary registrations will end at 11:59 pm Pacific Time.
Cancellation/Substitution
All cancellations (regardless of date) will be assessed with a $10 administrative fee.
All written notice of cancellations and substitutions should be sent via email to training@nhcaa.org. Cancellations received within 5 days of the date of purchase will result in a refund minus an administrative fee if the training has not occurred. No refunds will be issued if any portion of the Monthly On-Demand program has been viewed. Registrations are non-transferrable for monthly on-demand webinar.
Concerns
For more information regarding administrative policies such as refunds, cancellations and complaints, please email training@nhcaa.org.
Details & Frequently Asked Questions
Monthly On-Demand trainings are most appropriate for beginning and mid-career analysts, investigators, consultants, and law enforcement agents working in the health care anti-fraud industry.
As a level II, or intermediate program, some investigative / health care / coding expertise is assumed. Training content is focused on the detection and investigative processes, using case examples to highlight strategy and techniques.
There are no pre-requisite requirements to attend the Monthly On-Demand trainings.
All Monthly On-Demand trainings are approved by: NHCAA for 1 CPE
Participants earn 1 Continuing Professional Education (CPE) hours applicable to the training requirements for the Accredited Health Care Fraud Investigator (AHFI®) designation.Monthly On-Demand trainings are delivered via NHCAA Learn. You will need a good internet connection and an up-to-date version of Chrome, Firefox, Edge, or Safari. Internet Explorer is not recommended and will not render content correctly.
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