Fraud Waste and Abuse

Fraud, waste, and abuse (FWA) is believed to cost the US healthcare system billions of dollars annually and negatively impact clinical outcomes, further compounding cost of care.

Our FWA program is designed to improve clinical outcomes and lower total cost of care by providing prescribers and care teams the right information at the right time, allowing them to:

  • Better coordinate care by addressing high numbers of different therapies from multiple prescribers (polypharmacy)
  • Minimize overuse and misuse by refining drug regimens to align with documented standards of practice and proven therapy protocols
  • Address potential abuse of all controlled substances with emphasis on opioid and stimulant claims

Standard reporting and intervention programs as well as desk and on-site pharmacy audits are used to identify FWA trends, allowing us to target specific members, pharmacies, and prescribers that require further investigation.

Additionally, our unique retrospective drug use review offers health plans an efficient and accurate process for identifying cases of misuse and overuse with a focus on members who are flagged as having high probability for increased use and cost in the next 12 months. By applying risk-based metrics and look back claims history, we can reduce false positives and increase member stratification to inform the appropriate levels of engagement.

The FWA solution uses the John Hopkins ACG predictive risk scores to help identify those members at highest risk based on healthcare consumption. These insights coupled with our outcomes reporting help payers develop actionable plans for interventions to mitigate fraud, waste, and abuse or coordinate care.