June 4, 2018
Prime Therapeutics expands its Fraud, Waste, Abuse detection to include prescribers, patients
New agreement to deploy SAS’® analytics software tool allows for comprehensive FWA identification.
ST. PAUL, Minn. – To significantly reduce fraud, waste and abuse (FWA) that occurs with prescription drug claims, Prime Therapeutics LLC (Prime), a pharmacy benefit manager (PBM) serving more than 27 million members nationwide, is teaming up with SAS, a leader in health care analytics, to identify more areas that are prone to FWA activity and recover overpayments due to fraudulent claims. SAS’ deep analytic capabilities – using Prime’s integrated pharmacy claims and clients’ medical claims – will make Prime the first PBM to address FWA occurring among prescribers and members, in addition to pharmacies.
Fraud, waste and abuse costs the health care system tens of billions of dollars each year1. Prime has dedicated effort over the years to help protect its health plan clients and members from fraudulent activities that drive up health care costs for all. In 2017 alone, Prime’s fraud, waste and abuse program cut $211 million in potential waste. But, the nature of FWA means schemes continually evolve; and so does Prime’s approach to prevention and detection.
Typically, health plans conduct their own FWA programs among pharmacy claims paid under the medical benefit, while PBMs examine the claims on the pharmacy benefit. Now, Prime’s new analytics platform powered by SAS will offer complete integration of both the pharmacy and medical drug claims, along with medical services data. This efficiency is projected to save Prime’s clients more than $250 million in the next year by detecting, correcting and preventing FWA faster and more extensively than before.
According to Prime, one way this new analytics platform can help right away is to combat the opioid crisis. Opioid FWA occurs when people “doctor-shop” to get more medicines than appropriate by going to multiple doctors. It also occurs when pharmacies or patients create or alter prescription orders, or when prescribers overprescribe these drugs beyond guidelines, a practice that can have potentially deadly results. More broadly, the platform helps identify members who use deception to get prescriptions through insurance fraud, collusion with a pharmacy or prescriber, or stealing identities or prescriptions. The platform can also find prescribers who are falsely diagnosing patients, receiving kickbacks for certain medications or submitting duplicate claims.
“Most fraud, waste and abuse investigations are conducted in silos by platforms or organizations that don’t work together,” explained Jo-Ellen Abou Nader, assistant vice president of fraud, waste and abuse operations at Prime. “And while many PBMs and health plans may have pieces of data, integration of that data is what makes it most useful and efficient. The enhancements we will achieve through this SAS tool leapfrog Prime to the leading PBM in counteracting fraud, waste and abuse. We look forward to working with SAS to offer a complete fraud, waste and abuse program for our health plans.”
For more than 40 years, SAS has empowered organizations across industries to transform data into valuable insights with boundary-pushing analytic software and services. Aligning fraud detection, alert management and case management into a single platform, SAS® Detection and Investigation for Health Care improves investigational efficiency and helps reveal FWA before claims are paid. The solution also gives organizations the ability to harness the power of machine learning to continuously enhance fraud detection models and improve payment integrity at each stage of the claims process.
“The techniques typically used by health payers to detect fraud, waste and abuse have not kept pace with technological advances – a fact that has not gone unnoticed by opportunistic criminals,” said Stu Bradley, vice president of fraud and security intelligence at SAS. “The National Health Care Anti-Fraud Association estimates that outright fraud costs health care organizations an estimated $70 billion to $230 billion each year. Only 10 percent of such fraud is ever detected, and only 10 cents of each fraudulent dollar billed is ever recovered.”
“Prime Therapeutics is breaking new ground in shielding its health plan clients and members from such loss,” continued Bradley. “By integrating multi-sourced data and applying the varied analytic methodologies embedded within the solution, Prime will have the ability to better detect aberrant prescribing behavior, pharmacy rule violations and improper payments before they're made. This will save health plans hundreds of millions of dollars.”
1. www.nhcaa.org. (n.d.). Retrieved May 21, 2018, from https://www.nhcaa.org/media/127538/nhcaa_ushealthcaresystem_ 2017.pdf
About Prime Therapeutics
Prime Therapeutics LLC (Prime) helps people get the medicine they need to feel better and live well. Prime manages pharmacy benefits for health plans, employers, and government programs including Medicare and Medicaid. The company processes claims and offers clinical services for people with complex medical conditions. Prime serves more than 27 million people. It is collectively owned by 18 Blue Cross and Blue Shield Plans, subsidiaries or affiliates of those plans.
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Director, Corporate Communications