Combating

Fraud, Waste and Abuse

in the Prescription Drug

Benefit Plans
A Multi Billion Dollar Epidemic

US
AB
E

Prescriptiondrug
Prescriptiondrug
splitting&switching
splitting&switching

InappropriateBilling
InappropriateBilling
practices
practices Billing
Billing
multiplepayer,Brand
multiplepayer,Brand
versusGenericetc
versusGenericetc

Patientsusesdeceptive
Patientsusesdeceptive
methodsforover
methodsforover
prescriptionofcontrol
prescriptionofcontrol
substances
substances

Pharmaciesselling
Pharmaciesselling
controlsubstances
controlsubstances
unlawfully
unlawfully

It is no surprise that fraud and abuse in prescription drug

programs has exploded. In a recent report, epidemiologists at the
Centers for Disease Control and Prevention concluded that the
prescription drug problem is a crisis that is steadily worsening.
Backing this view are statistics showing that drug-related deaths
increased 96% from 2005-2010, with most of the jump due to
prescribed pain medications versus harder drugs like heroin or
cocaine. The technical challenge of sifting through the resulting
mountains of data for signs of suspicious behavior is formidable,
and it is one that has overwhelmed healthcare companies and law
enforcement agencies alike. In addition, the healthcare reform
landscape itself could offer potential opportunities to increase
fraud and abuse.

FR
AU
D

The USA is currently undergoing an epidemic of prescription

drug fraud and abuse that is estimated to be as high as $22
billion and which extends to both public and private programs.
Due to the rapid growth of the problem the industry, government
and law enforcement have been overwhelmed and have been
in a defensive mode. It is imperative therefore, that a paradigm
change that includes both pro-active analysis for new claims
as well as retrospective trending be used. Find out how HCL is
helping the stakeholders tackle the issue with new information
technology and strategies.

Key Challenges and Sources of

Fraud, Waste and Abuse

FWA
Practices

WASTE

Inappropriateformularydecision
Inappropriateformularydecision

Failuretooffernegotiatedprices
Failuretooffernegotiatedprices

Patientsnotusingthere
Patientsnotusingthere
medicineandreselling
medicineandreselling
orgivingittofamily
orgivingittofamily
members.
members.

Dispensingadulterated
Dispensingadulterated
orexpiredmedicine.
orexpiredmedicine.

Prescriptionrefillerrors
Prescriptionrefillerrors

TroopManipulation
TroopManipulation

Bait&switchingcost
Bait&switchingcost

HCL Solution Highlights

Analysis on 100% of Rx
Claims
Sort millions of claims
within minutes and detect
overpayment, process
errors, potential FWA and
misuses of benefits
Cost-effective platform for
greater financial results
Integrate to multiple points
including PBM and Payer
admin systems for Real
or near real time and
retrospective analysis

Our Approach
In traditional pharmacy claims processing environment detection systems have been unable
to answer the question Should we pay that claim?. HCLs solution focuses on enhancing the
fraud, waste and abuse discovery process through improved detection transparency in claims
processing from two distinct segments.
1. Real time or near real time predictive analysis on live claims by comparing claim against
claim history for a given patient and other data points.
2. Trend analysis on paid medical surgical and drug claims history to address physician prescribing patterns and alert the Payer.

The benefits to a payer include:

Improve Rx Claim payment accuracy and increase in annual profitability by

Including both real time and retrospective analytical capabilities

Having the flexibility to adhere to clients payment policies once F&A is discovered

Maximizing effectiveness in the discovery process by Interfacing with mobility techniques

as well as social networks

Ensuring adherence to all mandates of public or private programs

Cost-effective platform for greater financial return by

Scaling to address all aspects of fraud, waste and abuse across all channels

Identifying aberrancy within seconds and significantly reduce the FWA Management
spend on prescription claims

Building a secure environment that discourages future abuse by

Performing analytical data mining of medical and surgical claims to identify physician
prescribing practices, pharmacy dispensing trends and developing peer group scoring
patterns based on patient demographics, benefit or lines of business variations

Creating customizable dashboard with reporting capabilities to analyze risk and identifying
trends in billing practices

Ongoing support and research on trend analysis by solution experts with deep
understanding of the Healthcare Industry

A Technology Game Changer

The bottom line is that fraud and abuse of prescription drug benefit plans adds a new layer of
cost and complexity for healthcare industry stakeholders. The good news is that new information
technologies are showing real promise in the fight against fraud, waste and abuse. HCL is
among the leaders in developing integrated solutions that empower stakeholders to fully deploy
the power of Health IT.

For more information contact healthcare@hcl.com

Hello, Im from HCL! We work behind the scenes, helping our customers to shift paradigms and start revolutions.
We use digital engineering to build superhuman capabilities. We make sure that the rate of progress far exceeds
the price. And right now, 88,000 of us bright sparks are busy developing solutions for 500 customers in 31 countries
across the world. How can I help you?
www.hcltech.com