Next-generation data analytics helps fight pharmaceutical fraud


Next-generation data analytics can be used to help payers identify both drug purchasing and prescribing patterns that strongly suggest fraud and abuse.

Data analytics makes it easier to identify drug-seeking behavior among beneficiaries, and stop fraud on the part of pharmacies by comparing activity against a benchmark of patterns, Rena Bielinski, senior vice president and chief pharmacy officer at SCIO Health Analytics, and an accredited healthcare fraud investigator, wrote in an article for Internet Health Management. 

She described color-coded dashboards that can assign scores based on risk factors such as members seeing more than 10 physicians, or filling prescriptions at 10 or more pharmacies.

These next-generation analytics also can incorporate additional data such as addresses of beneficiaries, their doctors and the pharmacies being used in order to weed out legitimate drug-purchasing habits, she wrote. That’s because drug-seekers are more likely to be going to several pharmacies far from home.

In addition, establishing a benchmark of patterns for pharmacies and then monitoring activities against that benchmark can pinpoint possible fraud by pharmacies, according to the article. The metrics that can be monitored include rate of new billings, very high and very low reversal rates, an age-stratified count of average number of prescriptions per member, and the percentage of controlled substances dispensed.

While data analytics offers an "extremely powerful" tool to combat healthcare fraud, it must be used in tandem with traditional investigative work by field agents, Abhijit Dixit, an investigator of the Department of Health and Human Services’ Office of Inspector General, told Congress in late September. Good analytics can point investigators in the right direction, he added.