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How this company is fighting healthcare fraud with AI

This pharmacy benefit manager’s first-of-its kind initiative uses advanced analytics to find and fight fraud, saving health plans millions and improving patient care

How this company is fighting healthcare fraud with AI

Even at a conservative estimate, healthcare fraud costs the U.S. $68 billion annually, according to the National Health Care Anti-Fraud Association. These losses can inflate the costs of drugs and copays and waste providers’ time. Prime Therapeutics, a pharmacy benefit manager (PBM) collectively owned by 18 Blue Cross and Blue Shield plans, subsidiaries, or affiliates, is fighting back with a first-of-its-kind initiative that uses artificial intelligence (AI) from analytics software solutions provider SAS to weed out fraud, waste, and abuse (FWA).

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To realize value from the data collected, companies also need experienced employees who understand the information they review and what actions to take. Since launching the analytics platform in mid-2018, Prime Therapeutics’ investigators have saved health plans $355 million in recovered payments and cost avoidance. These savings help make medicine more affordable and earn Prime the No. 2 ranking in the health category on Fast Company‘s 2020 Most Innovative Companies list.

Bridging the gap between pharma and medical data

Jo-Ellen Abou Nader, vice president of FWA and supply chain optimization at Prime Therapeutics, explains that the issue “has always and will always exist,” but schemes change as healthcare evolves and as fraudsters adopt more sophisticated automated technology. Prime partnered with SAS to “tap into the power of big data” and to find fraud faster, she says.

Prime Therapeutics earned the standing of #2 in the Health category on our 2020 Most Innovative Companies List.

To Abou Nader’s knowledge, the AI platform is the first to integrate pharmacy and medical claims data from prescribers, pharmacies, and members so investigators can construct a holistic view of potential FWA. For example, investigators can link a patient’s prescriptions to a diagnosis and associated medical visits. The system’s visualization tools present the data in a compelling, easy-to-understand way, which improves communication with health plans and even law enforcement.

Integrating data also enables Prime to patrol for drug overutilization. Investigators use the system to suss out providers overprescribing opioids, pharmacies altering prescriptions, or patients demonstrating addictive behavior by seeking multiple prescriptions.

“Using controlled substances is appropriate if done the right way. That is where we come in—to help make sure they are being used appropriately and within the terms of the benefits. It can be a fine line,” explains Abou Nader.

Built to evolve with FWA trends and change

Dr. Steve Kearney, medical director at SAS, explains the platform uses advanced AI and machine learning (ML) to analyze massive amounts of data in real time and score anomalies, similar to how SAS runs credit risk analysis for banking clients. But the data’s value depends on an organization’s willingness and ability to analyze and act upon it, he says.

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For example, telemedicine has emerged as a hotbed for nefarious play, particularly in the wake of COVID-19. But in this new territory for many providers and partners, spotting potential fraud without experience is difficult. Prime has been working telemedicine cases for years and understands what routine telemedicine looks like, as well as when data anomalies do or do not make sense.

Specialty pharmacy is another emerging area of concern for health plans, because these drugs are expensive, and a growing number of Americans are on them, Abou Nader explains. SAS is bringing in a pharmacist to help build out AI around specialty pharmacy and improve Prime’s ability to spot this type of FWA quickly and effectively.

Schemes and tactics may change, but Prime believes it has the technology and talent in place to keep up with, or even ahead of, FWA. It also has a forward-thinking mindset. “You have to continue to think outside of the box and look at healthcare differently,” Abou Nader says. “It is not going to look the same in 10 years.”

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