Systems and methods for identifying fraud and abuse in prescription claims

• US 20030229519A1
• Filed: 05/16/2003
• Published: 12/11/2003
• Est. Priority Date: 05/16/2002
• Status: Abandoned Application

• Current Assignee: NDCHealth Corp. (McKesson Corp.)
• Original Assignee: NDCHealth Corp. (McKesson Corp.)
• Inventors: Eidex, Brian H., Rowe, James Couser III
• Application Number:
  US10/439,423
• Publication Number:
  US 20030229519A1
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 20/4016 involving fraud or risk level assessment in transaction processing
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients
• CPC Class Codes: G16H 50/20 for computer-aided diagnosis, e.g. based on medical expert systems
• CPC Class Codes: G16Z 99/00 Subject matter not provided for in other main groups of this subclass

Abstract

Systems and methods permit the identification of fraud and abuse in electronic prescription transactions by intercepting and analyzing prescription claims to determine the likelihood that a claim is fraudulent. A fraud scoring engine utilizes a compilation of expert rules and profiling engine methodologies to determine the likelihood that a transaction is the result of fraudulent or abusive behavior. The fraud scoring engine assigns a fraud score to rate the probability that a transaction is fraudulent in nature. The fraud score is compared against payer-defined business rules to determine if a claim is rejected as fraudulent. A fraud management interface enables payers to view a rejected claim and the reasons why a claim is rejected so that the reasons can be explained to a pharmacist, should the pharmacist contact the payer.

Claims

1. A method for identifying fraudulent prescription claims, comprising:

receiving a prescription claim, said prescription claim identifying a drug product and the pharmacy submitting said prescription claim;

analyzing the prescription claim to generate a fraud score, said fraud score based upon the likelihood that the prescription claim is fraudulent;

comparing said fraud score to business rules generated at least in part by a payer, wherein said business rules define a threshold value; and

rejecting said prescription claim as fraudulent where said fraud score exceeds said threshold value.

2. A computer-readable medium having stored thereon computer-executable instructions for performing the method of claim 1.

3. The method of claim 1, further comprising the step of processing said prescription claim where said fraud score fails to exceed said threshold value.

4. The method of claim 1, wherein said step of rejecting further comprises providing said pharmacy at least one reason code for rejecting said prescription claim.

5. The method of claim 1, wherein said step of rejecting further comprises providing said payer at least one reason code for rejecting said prescription claim.

6. The method of claim 1, wherein said step of analyzing comprises the step of analyzing the prescription claim to generate a fraud score, wherein said fraud score is based at least in part upon statistical information.

7. The method of claim 1, wherein said step of analyzing comprises the step of analyzing the prescription claim to generate a fraud score, wherein said fraud score is based at least in part upon expert rules established by the payer.

8. The method of claim 1, further comprising the step of forwarding said prescription claim to said payer where said fraud score fails to exceed said threshold value.

9. A system for identifying fraudulent prescription claims, comprising:

means for receiving a prescription claim, said prescription claim identifying a drug product and the pharmacy submitting said prescription claim; and

a processor functionally coupled to said means for receiving a prescription claim and configured for executing computer-executable instructions for;

analyzing the prescription claim to generate a fraud score, said fraud score based upon the likelihood that the prescription claim is fraudulent;

comparing said fraud score to business rules generated at least in part by a payer, wherein said business rules define a threshold value; and

rejecting said prescription claim as fraudulent where said fraud score exceeds said threshold value.

10. The system of claim 9, wherein said processor further includes computer-executable instructions for processing said prescription claim where said fraud score fails to exceed said threshold value.

11. The system of claim 9, wherein said processor further includes computer-executable instructions for providing said pharmacy at least one reason code for rejecting said prescription claim.

12. The system of claim 9, wherein said processor further includes computer-executable instructions for assigning at least one reason code to said prescription claim, wherein said at least one reason code indicates a reason for the generated fraud score.

13. The method of claim 9, wherein said processor further includes computer-executable instructions for analyzing the prescription claim to generate a fraud score, wherein said fraud score is based at least in part upon comparing said prescription claim to at least one statistical model.

14. The method of claim 9, wherein said processor further includes computer-executable instructions for analyzing the prescription claim to generate a fraud score, wherein said fraud score is based at least in part upon expert rules established by the payer.

15. The method of claim 9, wherein said processor further includes computer-executable instructions for forwarding said prescription claim to said payer where said fraud score fails to exceed said threshold value.

16. A system for identifying fraudulent prescription claims, comprising:

at least one pharmacy point-of-sale (POS) device; and

a host sever, in communication with said at least one pharmacy POS device via a network connection, wherein said host server comprises a fraud and abuse module, said fraud and abuse module comprising;

means for analyzing a prescription claim transmitted to said host server from said at least one pharmacy POS device, wherein said means for analyzing are operable to generate a fraud score corresponding to said prescription claim;

means for comparing said fraud score to at least one threshold value generated at least in part by a payer; and

means for rejecting said prescription claim as fraudulent where said fraud score exceeds said threshold value.

17. The system of claim 16, wherein said fraud and abuse module further comprises means for forwarding said prescription claim to said payer where said fraud score fails to exceed said threshold value.

18. The system of claim 16, wherein said means for analyzing comprises means for analyzing operable to generate at least one reason code associated with the prescription claim, wherein said at least one reason code indicates at least one reason for the generated fraud score.

19. The system of claim 18, wherein said fraud and abuse module fraud and abuse module further comprises means for forwarding said at least one reason code to the payer or the at least one pharmacy point-of-sale (POS) device.

20. The system of claim 16, wherein said means for analyzing comprise means for analyzing operable to generate a fraud score based at least in part upon a comparison of said prescription claim to at least one statistical model.