On April 20, UC filed suit in Los Angeles County Superior Court to stop what appears to be a fraud resulting in improper payments of nearly $12 million from UC's Student Health Insurance Plan (UC SHIP).
This alleged fraud involved contacting UC students — sometimes with offers of employment or offers of cash to participate in sham “clinical trials” — to obtain their insurance information. Students were then prescribed unnecessary medications that were charged to the health plan.
While UC SHIP is conducting an in-depth investigation with UC’s legal counsel and cooperating with law enforcement, UC is taking every reasonable step to protect our students, faculty, staff and retirees, and our medical plans, from this kind of abuse.
While UC is researching whether this fraud has extended to members of UC’s plans for faculty, staff and retirees, UC’s self-insured PPO plans are taking two immediate precautionary measures:
- Prescriptions costing over $3,000 will require a prior authorization form, completed by the provider and approved by the plan.
- Prescriptions written by the same providers or filling pharmacies, or for certain types of drugs, that were identified in the SHIP claims will be denied, pending an appeal from the member to confirm the prescription is appropriate.
These are likely to be temporary measures while UC determines the full impact of the issue. Unfortunately, however, these controls may still impact entirely appropriate prescriptions.
If members have any problems filling medically necessary prescriptions, they should call their plan’s prescription drug customer service number for assistance. UC will assess the continuing need for these measures as the investigation progresses.
You can read more about how to protect yourself from insurance fraud.