U.S. patent application number 14/247586 was filed with the patent office on 2014-08-07 for methods and systems for drug purchase validation.
This patent application is currently assigned to Express Scripts, Inc.. The applicant listed for this patent is Express Scripts, Inc.. Invention is credited to Jo-Ellen Abou Nader, Suzanne B. Mitchell.
Application Number | 20140222456 14/247586 |
Document ID | / |
Family ID | 50736582 |
Filed Date | 2014-08-07 |
United States Patent
Application |
20140222456 |
Kind Code |
A1 |
Abou Nader; Jo-Ellen ; et
al. |
August 7, 2014 |
METHODS AND SYSTEMS FOR DRUG PURCHASE VALIDATION
Abstract
Methods and systems for drug purchase validation are described.
In an example embodiment, drug sale data is accessed from a
prescription drug wholesaler regarding prescription drugs sold to
the pharmacy by the prescription drug wholesaler during a period of
time. A number of units of a prescription drug sold to the pharmacy
are determined based on the drug sale data during the period of
time. Pharmacy claims data over the period of time is accessed,
where the pharmacy claims data reflects a plurality of adjudicated
claims, and the plurality of adjudicated claims are a plurality of
claims that were submitted for adjudication by the pharmacy during
the period of time. A number of units of a prescription drug
associated with the plurality of claims submitted during the period
of time by the pharmacy for adjudication are determined based on
the pharmacy claims data. The number of units of the prescription
drug associated with the plurality of adjudicated claims that were
submitted for adjudication by the pharmacy is compared with the
number of units of the prescription drug sold to the pharmacy. A
determination is then made as to whether a discrepancy exists based
on the results of the comparison. Additional methods and systems
are disclosed.
Inventors: |
Abou Nader; Jo-Ellen;
(Chesterfield, MO) ; Mitchell; Suzanne B.;
(Belleville, IL) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
Express Scripts, Inc. |
St. Louis |
MO |
US |
|
|
Assignee: |
Express Scripts, Inc.
St. Louis
MO
|
Family ID: |
50736582 |
Appl. No.: |
14/247586 |
Filed: |
April 8, 2014 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
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13340809 |
Dec 30, 2011 |
8738399 |
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14247586 |
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Current U.S.
Class: |
705/2 |
Current CPC
Class: |
G16H 20/10 20180101;
G06Q 40/08 20130101 |
Class at
Publication: |
705/2 |
International
Class: |
G06F 19/00 20060101
G06F019/00 |
Claims
1. A method comprising: determining, by a processor, a sold amount
of a prescription drug sold by a prescription drug wholesaler to a
pharmacy during a retrospective time period based on prescription
drug wholesaler sale data of the prescription drug wholesaler;
determining, by the processor, an adjudicated claims amount of the
prescription drug associated with a plurality of adjudicated claims
for a corresponding time period to the retrospective time period,
the plurality of adjudicated claims being a plurality of claims of
the corresponding time period that were submitted on behalf of the
pharmacy and adjudicated and dispensing approved by a benefit
manager, the dispensing approved reflecting approval by the benefit
manager of the plurality of claims for dispensing by the pharmacy;
comparing, by the processor, the adjudicated claims amount of the
prescription drug associated with the plurality of adjudicated
claims with the sold amount of the prescription drug sold to the
pharmacy; and determining, by the processor, that a discrepancy
exists based on a result of the comparison reflecting that the
pharmacy has filled prescriptions for more prescription drugs than
the pharmacy has purchased.
2. The method of claim 1, where determining that the discrepancy
exists comprises: determining that the discrepancy exists where the
adjudicated claims amount that was submitted for adjudication by
the pharmacy is greater than the sold amount of the prescription
drug sold to the pharmacy by a predetermined level.
3. The method of claim 1, further comprising: generating a pharmacy
explanation request to request an explanation of the discrepancy
from the pharmacy; and transmitting the pharmacy explanation
request to a pharmacy device, the pharmacy device being associated
with the pharmacy.
4. The method of claim 1, further comprising: determining an excess
amount of the prescription drug associated with the plurality of
adjudicated claims that were submitted for adjudication by the
pharmacy greater than the sold amount of the prescription drug sold
to the pharmacy; generating a pharmacy reimbursement request for
reimbursement of the excess amount of the prescription drug.
5. The method of claim 1, further comprising: identifying a high
risk drug; accessing claims data submitted during a period of time
for the high risk drug by the pharmacy; determining a number of
high risk drug adjudicated claims relating to the high risk drug
during the period of time based on the claims data; and selecting
the pharmacy for verification where the number of claims submitted
by the pharmacy relating to the high risk drug is greater than a
verification criterion.
6. The method of claim 5, where the verification criterion is a
determined amount of adjudicated claims associated with the high
risk drug.
7. The method of claim 1, further comprising: harmonizing the sold
amount of the prescription drug sold to the pharmacy with the
adjudicated claims amount of the prescription drug submitted by the
pharmacy for adjudication such that a number of doses, dosage, and
capsule type for each are of a comparable type.
8. The method of claim 1, further comprising: identifying the
prescription drug wholesaler that sell the prescription drug to the
pharmacy; and transmitting a drug sale data request to a
prescription drug wholesaler device associated with the
prescription drug wholesaler.
9. The method of claim 1, further comprising: generating a
physician verification request for requesting verification of a
claim from a physician; and transmitting the physician verification
request to a physician device, the physician device being
associated with a physician.
10. The method of claim 1, further comprising: generating a patient
verification request for requesting verification of a claim from a
patient; and transmitting the patient verification request to a
patient device, the patient device being associated with a
patient.
11. The method of claim 1, where drug sale data includes invoice
data relating to sales of drugs from the prescription drug
wholesaler to the pharmacy.
12. The method of claim 1, wherein adjudication by the benefit
manager includes eligibility verification, co-pay determination,
and drug utilization review.
13. The method of claim 1, wherein the prescription drug wholesaler
purchased the prescription drug from a drug manufacturer of the
prescription drug and sold the prescription drug to the
pharmacy.
14. The method of claim 1, wherein the prescription drug wholesaler
sale data includes data received from a drug wholesaler in response
to an inquiry regarding specific quantities of the prescription
drug sold to the pharmacy.
15. A non-transitory machine-readable medium comprising
instructions, which when executed by one or more processors, cause
the one or more processors to perform the following operations:
determine a sold amount of a prescription drug sold by a
prescription drug wholesaler to a pharmacy during a retrospective
time period based on prescription drug wholesaler sale data of the
prescription drug wholesaler; determine an adjudicated claims
amount of the prescription drug associated with a plurality of
adjudicated claims for a corresponding time period to the
retrospective time period, the plurality of adjudicated claims
being a plurality of claims of the corresponding time period that
were submitted on behalf of the pharmacy and adjudicated and
dispensing approved by a benefit manager, the dispensing approved
reflecting approval by the benefit manager of the plurality of
claims for dispensing by the pharmacy; compare the adjudicated
claims amount of the prescription drug associated with the
plurality of adjudicated claims with the sold amount of the
prescription drug sold to the pharmacy; and determine that a
discrepancy exists based on a result of the comparison reflecting
that the pharmacy has filled prescriptions for more prescription
drugs than the pharmacy has purchased.
15. A system comprising: a processor and a memory; a subsystem
deployed in the memory and executed by the processor to determine a
sold amount of a prescription drug sold by a prescription drug
wholesaler to a pharmacy during a retrospective time period based
on prescription drug wholesaler sale data of the prescription drug
wholesaler, determine an adjudicated claims amount of the
prescription drug associated with a plurality of adjudicated claims
for a corresponding time period to the retrospective time period,
the plurality of adjudicated claims being a plurality of claims of
the corresponding time period that were submitted on behalf of the
pharmacy and adjudicated and dispensing approved by a benefit
manager, the dispensing approved reflecting approval by the benefit
manager of the plurality of claims for dispensing by the pharmacy,
compare the adjudicated claims amount of the prescription drug
associated with the plurality of adjudicated claims with the sold
amount of the prescription drug sold to the pharmacy, and determine
that a discrepancy exists based on a result of the comparison
reflecting that the pharmacy has filled prescriptions for more
prescription drugs than the pharmacy has purchased.
Description
CROSS REFERENCE TO RELATED APPLICATION
[0001] This application claims priority to and is a continuation of
U.S. patent application Ser. No. 13/340,809 filed on Dec. 30, 2011,
entitled "Methods and Systems for Drug Purchase Validation" the
entire disclosure of which is incorporated herein by reference.
FIELD
[0002] The field relates to fraud detection, and more particularly
to electronic verification of prescription drug sales by a
pharmacy.
BACKGROUND
[0003] Pharmacy benefit managers (PBMs) offer prescription drug
benefit plans that allow members to have drug prescriptions filled
at various in-network pharmacy locations. These locations may
include retail locations, mail locations, or both retail and mail
locations.
[0004] When a physician writes a prescription for a patient, the
patient takes the prescription to a pharmacy to have the
prescription filled. The pharmacy submits the prescription to the
PBM for adjudication, fills the prescription, and accepts a co-pay
from the patient. Once the PBM adjudicates the matter, it
reimburses the pharmacy a predetermined amount for the specific
drug sold to the patient. The pharmacy then purchases additional
doses of the drug prescribed to the patient from a drug wholesaler
in order to refill its stock.
BRIEF DESCRIPTION OF THE DRAWINGS
[0005] FIG. 1 is a block diagram of an example network of a
pharmacy, a drug wholesaler and a PBM, according to an example
embodiment.
[0006] FIG. 2 is a block diagram of an example purchase validation
device, according to an example embodiment;
[0007] FIG. 3 is a block diagram of an example pharmacy selection
subsystem, according to an example embodiment.
[0008] FIG. 4 is a block diagram of an example drug sale and
adjudication information subsystem, according to an example
embodiment.
[0009] FIG. 5 is a block diagram of an example drug quantity
extraction subsystem, according to an example embodiment.
[0010] FIG. 6 is a block diagram of an example pharmacy follow-up
subsystem.
[0011] FIG. 7 is an example process flow illustrating a method for
purchase verification of adjudicated claims, according to an
example embodiment.
[0012] FIG. 8 is an example process flow illustrating a method for
investigating possible fraud, according to an example
embodiment.
[0013] FIG. 9 is a block diagram of a machine in the example form
of a computer system within which a set of instructions for causing
the machine to perform any one or more of the methodologies
discussed herein may be executed or stored.
DETAILED DESCRIPTION
[0014] The purchase verification system and method may protect
against the proliferation of prescription drugs, such as the
addictive class C-2 narcotics, and may help to prevent the
fraudulent submission of prescription claims for adjudication by a
PBM. The purchase verification system and method monitors the
quantity of prescription drugs distributed to a pharmacy and the
quantity of prescription drugs reportedly dispensed by the
pharmacy, and determines whether there are any discrepancies which
would indicate that the pharmacy has submitted claims to the PBM
for more doses of a given drug than the pharmacy has purchased.
[0015] A discrepancy is detected by the purchase validation device
which accesses information relating to drugs sold to a pharmacy, as
well as information regarding claims submitted for adjudication by
the pharmacy to a PBM. The purchase validation device determines
therefrom data regarding units of a prescription drug, which may
include the number and type of drugs purchased by the pharmacy
and/or reportedly dispensed by the pharmacy. By analyzing this
data, the purchase validation device may determine that a pharmacy
has reportedly filled prescriptions for more drugs than it has
purchased, which may indicate fraud.
[0016] FIG. 1 illustrates a block diagram of an example system, as
described above, according to an example embodiment. The system 100
is an example environment in which the claims associated with a
pharmacy may be verified. The system 100, as shown in FIG. 1,
includes a pharmacy device 102, a benefit manager device 106, a
drug wholesale device 108, and a purchase validation device
110.
[0017] The pharmacy device 102 may be in communication with a
benefit manager device 106 over a network 104. The pharmacy device
102 may be operated by a pharmacy (which may be a retail pharmacy,
a mail order pharmacy, a specialty pharmacy, or the like), or an
entity that is at least partially responsible for submitting
prescription claims to a PBM.
[0018] The network 104 by which the pharmacy device 102
communicates with the benefit manager device 106 may include, by
way of example, Mobile Communications (GSM) network, a code
division multiple access (CDMA) network, 3rd Generation Partnership
Project (3GPP), an Internet Protocol (IP) network, a Wireless
Application Protocol (WAP) network, a WiFi network, or an IEEE
802.11 standards network, as well as various combinations thereof.
Network 104 may also include optical or wired communications. Other
conventional and/or later developed wired and wireless networks may
also be used.
[0019] The benefit manager device 106 is a device operated by an
entity at least partially responsible for creation and/or
management of the pharmacy benefit. While the benefit manager
operating the benefit manager device 106 is typically a PBM, other
entities may operate the benefit manager device 106 either on
behalf of themselves, the PBM, or another entity.
[0020] Some of the operations of the PBM that operates the benefit
manager device 106 may include the following. A member (or a person
on behalf of the member) attempts to obtain a prescription drug at
a retail pharmacy location where the member can obtain drugs in a
physical store from a pharmacist or pharmacist technician, or in
some instances through mail order drug delivery from a mail order
pharmacy location.
[0021] The member may have a co-pay for the prescription drug that
reflects an amount of money that the member is responsible to pay
the pharmacy for the prescription drug. The money paid by the
member to the pharmacy may come from the personal funds of the
member, a health savings account (HSA) of the member or the
member's family, a health reimbursement arrangement (HRA) of the
member or the member's family, a flexible spending accounts (FSA)
of the member or the member's family, or the like. An employer of
the member may directly or indirectly fund or reimburse the member
or an account of the member for the co-pay.
[0022] The amount of the co-pay paid by the member may vary by the
benefit plan of the client with the PBM. The member's co-pay may be
based on be a flat co-pay (e.g., $10), co-insurance (e.g., 10%),
and/or a deductible (e.g., for first $500 of annual prescription
drug spend) for certain prescription drugs, certain types of
prescription drugs, and/or all prescription drugs.
[0023] In certain instances, the member may not pay the co-pay or
may only pay for a portion of a co-pay for a prescription drug. For
example, if the usual and customary cost for a generic version of a
prescription drug is $4, and the member's flat co-pay is $20 for
the prescription drug, the member may only pay $4 to receive the
prescription drug. In another example involving a worker's
compensation claim, no co-pay may be due by the member for the
prescription drug.
[0024] In conjunction with receiving the co-pay (if any) from the
member and dispensing the prescription drug to the member, the
pharmacy submits a claim to the PBM for the prescription drug. The
PBM may perform certain adjudication functions including verifying
the eligibility of the member, reviewing the formulary to determine
appropriate co-pay, coinsurance, and deductible for the
prescription drug, and performing a drug utilization review (DUR)
on the member. The PBM then adjudicates the claim associated with
the prescription drug and provides a response to the pharmacy
following performance of the aforementioned functions. As part of
the adjudication, the client (or the PBM on behalf of the client)
ultimately reimburses the pharmacy for filling the prescription
drug when the prescription drug was successfully adjudicated. The
aforementioned adjudication functions generally occur before the
co-pay is received and the prescription drug dispensed. However,
the operations may occur simultaneously, substantially
simultaneously, or in a different order. In addition, more or less
adjudication functions may be performed as part of the adjudication
process.
[0025] The amount of reimbursement paid to the pharmacy by the
client and/or member may be based at least in part on the type of
pharmacy network in which the pharmacy is included. Other factors
may be used to determine the reimbursement amount in addition to
the type of pharmacy network.
[0026] The wholesaler device 108 may be operated by a drug
wholesaler, or an entity that is at least partially responsible
buying drugs from a drug manufacturer and/or for selling drugs to
pharmacies. Either or both of the pharmacy device 102 and benefit
manager device 106 may be in communication with the wholesaler
device 108 via network 104.
[0027] After a pharmacy has submitted a claim to a PBM for
adjudication and fills the patient's prescription, the pharmacy
purchases additional drugs from a drug wholesaler to refill its
depleted stock. However, patients, doctors and/or pharmacies may
attempt to abuse the system. For example, a pharmacy may submit
claims to the PBM for adjudication of and payment for prescriptions
which the pharmacy did not fill.
[0028] The purchase validation device 110, which may be operated by
a PBM or a third party responsible for verifying certain claims
submitted for adjudication, may therefore be in communication with
benefit manager device 106, wholesaler device 108 and/or pharmacy
device 102 over the network 104. The purchase validation device 110
may a part of the benefit manager device 106, or a separate device
therefrom. The purchase validation device 110, the benefit manager
device 106, the wholesaler device 108, and the pharmacy device 102
may each be electronic device and/or a computer system which
include at least one processor.
[0029] The purchase validation device 110 may be in communication
directly (e.g., through local storage) and/or through the network
104 (e.g., in a cloud configuration or software as a service) with
a database 112. The database 112 may store pharmacy claims data
114, pharmacy data 116 and drug wholesaler data 118.
[0030] The pharmacy claims data 114 includes data relating to
claims adjudicated by the PBM including monies paid to pharmacies
as a result. The pharmacy claims data 114 generally reflects
multiple adjudicated claims that were submitted by the pharmacy for
adjudication during a period of time. A claim may be associated
with a single prescription drug or multiple prescription drugs. The
pharmacy data 116 includes data received from pharmacies, such as
lists of drug wholesalers from which the pharmacies purchase drugs.
The drug wholesaler data 118 includes data received from a drug
wholesaler regarding specific quantities of drugs sold to a
pharmacy.
[0031] While the system 100 in FIG. 1 is shown to include single
devices 102, 106, 108, 110, 112, multiple devices may be involved.
Such devices may be of the same type, or of different types.
Network 104 may be multiple networks, which may communicate in
series with each other or in parallel with one another and the
devices in system 100.
[0032] FIG. 2 illustrates a block diagram of an example purchase
validation device 110 according to an example embodiment. The
purchase validation device 110 may include a pharmacy selection
subsystem 202, a drug sale and adjudication information subsystem
204, a drug quantity extraction subsystem 206, and a pharmacy
follow-up subsystem 208.
[0033] In general operation, the pharmacy selection subsystem 202
may flag pharmacies that have an elevated probability of being
involved in fraudulent activity. A pharmacy which submits a high
percentage of claims for drugs with high reimbursement amounts may
be flagged, as may pharmacies which submit a high percentage of
claims for drugs which are commonly abused.
[0034] The drug sale and adjudication information subsystem 204
requests and collects drug purchase information from a pharmacy and
drug wholesaler, and aggregating claim adjudication data for the
flagged pharmacies. Such drug purchase information may include the
number and types of pharmaceuticals purchased by a pharmacy from a
drug wholesaler, as well as the number and types of pharmaceuticals
associated with claims submitted for adjudication by the pharmacy.
This may include the number of units of a prescription drug by
dosage, drug type, capsule type, method of administration, and the
like, and may be indicated by National Drug Code (NDC).
[0035] The drug quantity extraction system 206 determines the
number and type of drugs sold to the pharmacy based on the drug
purchase information, and for determining the number and type of
drugs associated with the claims submitted for adjudication by the
pharmacy based on the pharmacy claims data. Such numbers may also
be harmonized to account for different counting conventions among
drug wholesalers, pharmacies, and PBMs. The drug quantity
extraction subsystem 206 may analyzing the number of drug doses
purchased by the pharmacy and submitted to the PBM for adjudication
by the pharmacy to determine if there are any discrepancies.
[0036] FIG. 3 illustrates an example pharmacy selection subsystem
202 that may be deployed in the purchase validation device 110, the
benefit manager device 106, or otherwise deployed in another
system. One or more modules are communicatively coupled and
included in the pharmacy selection subsystem 202 to enable a
pharmacy to be selected for purchase verification. The modules of
the pharmacy selection subsystem 202 that may be included are a
high risk drug determination module 302, a pharmacy record access
and review module 304 and a high risk pharmacy flagging module 306.
Other modules may also be included.
[0037] In some embodiments, the modules of the pharmacy selection
subsystem 202 may be distributed so that some of the modules are
deployed in the benefit manager device 106 and some are deployed in
the purchase validation device 110. In one embodiment, the modules
are deployed in memory and executed by a processor coupled to the
memory. The functionality contained within modules 302-306 may be
combined into a lesser number of modules, further divided among a
greater number of modules, or redistributed among existing modules.
Other configurations including the functionality of the modules may
be used.
[0038] High risk drug determination module 302 may first determine
which drugs, if any, are the most likely to be exploited via fraud.
For example, drugs which provide pharmacies with a high
reimbursement rate upon adjudication are often targets for
pharmacies attempting to commit fraud. Submitting relatively few
false claims for adjudication can result in sizeable payments from
the PBM to the pharmacy. Similarly, drugs which are in high demand
(such as pain medications, HGH, etc.) may also be flagged as high
risk drugs by high risk drug determination module 302, as large
numbers of these prescriptions could signal that a patient and/or
doctor and/or pharmacy are operating a so-called "pill mill."
Further criteria may include low reversal rates, higher than
industry or geographical average sales, etc. The selection of high
risk drugs may be automatic, or may be made manually input (e.g.,
by a device operator).
[0039] Pharmacy record review module 304 then accesses and reviews
pharmacy adjudication records, such as those stored as the pharmacy
claims data 114 and/or the pharmacy data 116, stored in the
database 112. Claim adjudications involving high risk drugs are
selected for evaluation and analysis. The high risk flagging module
306 then calculates whether the numbers of such selected claims are
higher than a predetermined threshold. Where a pharmacy's high risk
drug claim adjudications are below the predetermined threshold, no
action is taken. However, where the pharmacy's high risk drug claim
adjudications surpass the threshold, the high risk flagging module
306 identifies or flags the pharmacy for verification of the claims
it submitted for adjudication.
[0040] FIG. 4 illustrates a block diagram of an example drug sale
and adjudication information subsystem 204 according to an example
embodiment, which may be deployed in the purchase validation device
110, the benefit manager device 106, or otherwise deployed in
another system. One or more modules are communicatively coupled and
included in the drug sale and adjudication information subsystem
204 to enable data to be collected regarding drug sales and claims
submitted for adjudication. Drug sale and adjudication information
subsystem 204 may include a pharmacy communication module 402, a
drug wholesaler communication module 404, and a data access module
406. Other modules may also be included
[0041] In some embodiments, the modules of the drug sale and
adjudication information subsystem 204 may be distributed so that
some of the modules are deployed in the benefit manager device 106
and some are deployed in the purchase validation device 110. In one
embodiment, the modules are deployed in memory and executed by a
processor coupled to the memory. The functionality contained within
modules 402-406 may be combined into a lesser number of modules,
further divided among a greater number of modules, or redistributed
among existing modules. Other configurations including the
functionality of the modules may be used.
[0042] The pharmacy communication module 402 may initiate
communication with the pharmacy device 102 associated with a
flagged pharmacy, either via email (such as through network 104),
fax, or the like. The pharmacy communication module 402 may request
that the pharmacy device instruct the pharmacy's drug wholesaler to
transmit the drug wholesaler data 118 (which may include drug sale
data) to the PBM regarding drugs sold by the drug wholesaler to the
pharmacy during a period of time. Drug sale data may include
invoice data and/or information relating to the number and type of
unit of prescription drug sold. The drug wholesaler communication
module 404 may then communicate with the wholesaler device 108, and
receive drug wholesaler data therefrom. In some embodiments, the
pharmacy device 102 may simply identify to the pharmacy
communication module 404 the pharmacy's drug wholesaler. The drug
wholesaler communication module 404 may then initiate communication
with the wholesaler device 108 to receive the drug wholesaler data
118. The received drug wholesaler data 118 is stored in database
112. In some embodiments, pharmacies generally agree ahead of time
to such audit procedures when signing on to be a part of a pharmacy
network of a PBM.
[0043] The data access module 406 then accesses the drug wholesaler
data 118 and the drug sale data therein, as well as the pharmacy
claims data 114 from the database 112 to retrieve claim
adjudication data submitted by the flagged pharmacy over the
selected period of time.
[0044] FIG. 5 illustrates an example drug quantity extraction
subsystem 206 according to an example embodiment, which may be
deployed in the purchase validation device 110, the benefit manager
device 106, or otherwise deployed in another system. One or more
modules are communicatively coupled and included in the drug
quantity extraction subsystem 206 to enable the determination of
units of a prescription drugs sold to and submitted for
adjudication by a pharmacy. Drug quantity extraction subsystem 206
may include a wholesaler drug unit extraction module 502, a claims
drug unit extraction module 504, a drug unit harmonization module
506, and a discrepancy determination module 508. Other modules may
also be included
[0045] In some embodiments, the modules of the drug quantity
extraction subsystem 206 may be distributed so that some of the
modules are deployed in the benefit manager device 106 and some are
deployed in the purchase validation device 110. In one embodiment,
the modules are deployed in memory and executed by a processor
coupled to the memory. The functionality contained within modules
502-508 may be combined into a lesser number of modules, further
divided among a greater number of modules, or redistributed among
existing modules. Other configurations including the functionality
of the modules may be used.
[0046] Wholesaler drug unit extraction module 502 parses the
accessed drug wholesaler data 118, and determines and/or extracts
data regarding units of a prescription drug sold to the pharmacy
therefrom. Indeed, the wholesaler devices 108 may merely transmit
electronic copies of invoices and/or spreadsheets of data which are
not standardized. Such documents may require the wholesaler drug
unit extraction module 502 to perform optical character recognition
(OCR) thereon to extract the data regarding units of a prescription
drug sold to the pharmacy contained therein. In some embodiments,
the wholesaler drug unit extraction module 502 may extract data
regarding units of a prescription drug sold to the pharmacy from
spreadsheets or other formatting of data received from the
wholesaler devices 108.
[0047] The claims drug unit extraction module 504 determines and/or
extracts data regarding units of a prescription drug submitted for
adjudication by the pharmacy in the accessed pharmacy claims data
114. As discussed above, data regarding units of a prescription
drug may include the quantity and type of drugs sold to pharmacies
or submitted by the pharmacies to PBMs for adjudication, and may
include a drug's National Drug Code (NDC), drug name, drug maker,
quantity per prescription, capsule type, dosage, number of doses
and the like. The NDC serves as a universal product identifier for
human drugs. The FDA publishes the listed NDC numbers and
information submitted as part of the listing information in the NDC
Directory. For a PBM service performing a purchase validation, the
NDC identifier number may identify the same products when purchased
from one or more different wholesalers.
[0048] Different drug wholesalers and PBMs may have different drug
unit numbering conventions. For example, birth control pills are
generally sold in three-packs of thirty pills each, which may be
considered: a single unit, three units, or ninety individual doses,
depending on the entity classifying the drug sale/adjudication. The
drug unit harmonization module 506 considers such varying reporting
conventions, and harmonizes the data regarding units of a
prescription drug from the drug wholesaler data 118 and the data
regarding units of a prescription drug from the pharmacy claims
data 114. Such harmonization creates a direct, one-to-one,
drug-for-drug, pill-for-pill, dose-for-dose comparison between
drugs purchased by the pharmacy and drug claims reimbursed by the
PBM.
[0049] The discrepancy determination module 508 then compares the
number of units of a prescription drug submitted for adjudication
by the pharmacy with the number of units of a prescription drug
sold to the pharmacy by the drug wholesaler. Where the pharmacy has
requested adjudication for more of a given drug than it has
actually purchased by a threshold amount, the discrepancy
determination module 508 detects that fraud may have occurred.
[0050] FIG. 6 illustrates an example pharmacy follow-up subsystem
208 according to an example embodiment, which may be deployed in
the purchase validation device 110, the benefit manager device 106,
or otherwise deployed in another system. One or more modules are
communicatively coupled and included in the pharmacy follow-up
subsystem 208 to enable further investigation of any discrepancies
found. The pharmacy follow-up subsystem 208 may include a pharmacy
communication module 602, a physician communication module 604, a
patient communication module 606, and a billing module 608. Other
modules may also be included
[0051] In some embodiments, the modules of the pharmacy follow-up
subsystem 208 may be distributed so that some of the modules are
deployed in the benefit manager device 106 and some are deployed in
the purchase validation device 110. In one embodiment, the modules
are deployed in memory and executed by a processor coupled to the
memory. The functionality contained within modules 602-608 may be
combined into a lesser number of modules, further divided among a
greater number of modules, or redistributed among existing modules.
Other configurations including the functionality of the modules may
be used.
[0052] The pharmacy communication module 602 may transmit to the
pharmacy device 102 a request for additional
explanation--essentially, an explanation as any discrepancies
between the units of a prescription drug submitted for adjudication
and the number of units of a prescription drug purchased by the
pharmacy. The request may be generated dynamically or
automatically. To verify the claims submitted by the pharmacy for
adjudication, the physician communication module 604 may transmit a
request to the physician or other type of prescriber who wrote a
prescription at issue (or to a prescriber device associated with
the prescriber). The patient communication module 606 may do the
same with a patient (or a patient device) whose prescription is at
issue. Responses by a patient, physician, or the pharmacy may be
received and reviewed electronically, or manually.
[0053] The billing module 608 may transmit to the pharmacy device
102 a bill for cost and reimbursement amounts associated with
adjudicating drug claims above the number of units of a
prescription drug purchased by the pharmacy. The bill (or pharmacy
reimbursement request) may be transmitted electronically, faxed,
mailed, or otherwise provided to the pharmacy.
[0054] FIG. 7 illustrates a method 700 for purchase verification of
adjudicated claims, according to an example embodiment. The method
700 may be performed by the purchase validation device 110,
partially by the purchase validation device 110 and partially by
the benefit manager device 106, or may be otherwise
implemented.
[0055] At block 702, a pharmacy is selected for review based on its
adjudication data. As discussed above, a pharmacy which submits
higher than expected numbers of claims involving expensive drugs,
high demand drugs, low reversal rates, etc. may be selected for
review.
[0056] At block 704, the drug sale data from the pharmacy's
wholesaler is accessed, along with the claims that were submitted
by the pharmacy to the PBM for adjudication. The data from the
pharmacy's wholesaler may have been received in the form of
invoices, electronically via spreadsheet, or in another form. The
data regarding claims submitted by the pharmacy to the PBM for
adjudication may be stored in an accessible database by the
PBM.
[0057] At block 706, data regarding the number of units of a
prescription drug is determined based on the drug sale data and the
adjudicated claims, and in some embodiments, is harmonized. The
data regarding the number of units of a prescription drug may be
determined based on and/or extracted from the drug sale data and
adjudicated pharmacy claims data. Harmonization of the various data
regarding the number of units of a prescription drug may also be
performed, considering the varying reporting conventions. Such
harmonization creates a direct, one-to-one, drug-for-drug,
pill-for-pill, dose-for-dose comparison between drugs purchased by
the pharmacy and drug claims reimbursed by the PBM.
[0058] At block 708, the number of units of a prescription drug in
the adjudicated claims is compared with the number of units of a
prescription drug sold by the wholesaler. As the number of units of
a prescription drug from the adjudicated claims represents the
number, type, dose, etc. of the drugs reportedly dispensed by the
pharmacy, while the number of units of a prescription drug sold by
the wholsalers represents the number, type, dose, etc. of the drugs
sold to the pharmacy, a comparison of such data can detect that a
pharmacy submitted a claim (and received a reimbursement) for a
drug which it never purchased. Thus, at block 710, discrepancies
are detected and noted as possible fraud.
[0059] FIG. 8 illustrates a method 800 for investigating possible
fraud, according to an example embodiment. The method 800 may be
performed by the purchase validation device 110, partially by the
purchase validation device 110 and partially by the benefit manager
device 106, or may be otherwise implemented.
[0060] At block 802, where a possible fraud has been detected, a
request is transmitted to the pharmacy for clarification as to the
seemingly fraudulent activity. The pharmacy may be asked to explain
the detected discrepancies, and/or provide additional data to
support the claims it submitted.
[0061] At block 804, a determination is made as to whether to
transmit an additional information request to an associated
physician. Such a physician may be able to confirm whether an
adjudicated claim is legitimate, or was contrived by the pharmacy
and/or patient. Where such a transmission is to be made, at block
806, the request for verification is transmitted to the physician
(or physician device).
[0062] Similarly, at block 808, a determination is made as to
whether to transmit an additional information request to an
associated patient. Such a patient may be able to confirm whether
an adjudicated claim is legitimate, or was contrived by the
pharmacy and/or physician. Where such a transmission is to be made,
at block 810, the request for verification is transmitted to the
patient (or patient device).
[0063] At block 812, responses are received, and a determination is
made as to whether the responses clarify the circumstances of the
possible fraud as being legitimate. This step may be manual or
computerized. Where a pharmacy provides additional wholesaler from
which it bought drugs, any such additional drug purchases may be
investigated via the purchase verification method above.
[0064] At block 814, where a possible fraud has been detected and
has not been ruled out, a bill is generated and transmitted to the
pharmacy requesting repayment of costs and reimbursement amounts
associated with adjudicating the fraudulent claims.
[0065] FIG. 9 shows a block diagram of a machine in the example
form of a computer system 900 within which a set of instructions
may be executed causing the machine to perform any one or more of
the methods, processes, operations, or methodologies discussed
herein. The pharmacy device 102, the benefit manager device 106,
the wholesaler device 108 and/or the purchase validation device 110
may include the functionality of one or more computer systems
900.
[0066] In an example embodiment, the machine operates as a
standalone device or may be connected (e.g., networked) to other
machines. In a networked deployment, the machine may operate in the
capacity of a server or a client machine in server-client network
environment, or as a peer machine in a peer-to-peer (or
distributed) network environment. The machine may be a server
computer, a client computer, a personal computer (PC), a tablet PC,
a gaming device, a set-top box (STB), a Personal Digital Assistant
(PDA), a cellular telephone, a web appliance, a network router,
switch or bridge, or any machine capable of executing a set of
instructions (sequential or otherwise) that specify actions to be
taken by that machine. Further, while only a single machine is
illustrated, the term "machine" shall also be taken to include any
collection of machines that individually or jointly execute a set
(or multiple sets) of instructions to perform any one or more of
the methodologies discussed herein.
[0067] The example computer system 900 includes a processor 902
(e.g., a central processing unit (CPU) a graphics processing unit
(GPU) or both), a main memory 904 and a static memory 906, which
communicate with each other via a bus 908. The computer system 900
further includes a video display unit 910 (e.g., a liquid crystal
display (LCD) or a cathode ray tube (CRT)). The computer system 900
also includes an alphanumeric input device 912 (e.g., a keyboard),
a cursor control device 914 (e.g., a mouse), a drive unit 916, a
signal generation device 918 (e.g., a speaker) and a network
interface device 920.
[0068] The drive unit 916 includes a computer-readable medium 922
on which is stored one or more sets of instructions (e.g., software
924) embodying any one or more of the methodologies or functions
described herein. The software 924 may also reside, completely or
at least partially, within the main memory 904 and/or within the
processor 902 during execution thereof by the computer system 900,
the main memory 904 and the processor 902 also constituting
computer-readable media.
[0069] The software 924 may further be transmitted or received over
a network 926 via the network interface device 920.
[0070] While the computer-readable medium 922 is shown in an
example embodiment to be a single medium, the term
"computer-readable medium" should be taken to include a single
medium or multiple media (e.g., a centralized or distributed
database, and/or associated caches and servers) that store the one
or more sets of instructions. The term "computer-readable medium"
shall also be taken to include any medium that is capable of
storing or encoding a set of instructions for execution by the
machine and that cause the machine to perform any one or more of
the methodologies of the present invention. The term
"computer-readable medium" shall accordingly be taken to include,
but not be limited to, solid-state memories, and optical media, and
magnetic media. In some embodiments, the computer-readable medium
is a non-transitory computer-readable medium.
[0071] The term "based on" or using, as used herein, reflects an
open-ended term that can reflect others elements beyond those
explicitly recited.
[0072] Certain systems, apparatus, applications or processes are
described herein as including a number of modules. A module may be
a unit of distinct functionality that may be presented in software,
hardware, or combinations thereof. When the functionality of a
module is performed in any part through software, the module
includes a computer-readable medium. The modules may be regarded as
being communicatively coupled.
[0073] The inventive subject matter may be represented in a variety
of different embodiments of which there are many possible
permutations.
[0074] In an example embodiment, drug sale data is accessed from a
prescription drug wholesaler regarding prescription drugs sold to
the pharmacy by the prescription drug wholesaler during a period of
time. A number of units of a prescription drug sold to the pharmacy
are determined based on the drug sale data during the period of
time. Pharmacy claims data over the period of time is accessed,
where the pharmacy claims data reflects a plurality of adjudicated
claims, and the plurality of adjudicated claims are a plurality of
claims that were submitted for adjudication by the pharmacy during
the period of time. A number of units of a prescription drug
associated with the plurality of claims submitted during the period
of time by the pharmacy for adjudication are determined based on
the pharmacy claims data. The number of units of the prescription
drug associated with the plurality of adjudicated claims that were
submitted for adjudication by the pharmacy is compared with the
number of units of the prescription drug sold to the pharmacy. A
determination is then made as to whether a discrepancy exists based
on the results of the comparison.
[0075] Thus, methods and systems for purchase verification have
been described. Although embodiments of the present invention have
been described with reference to specific example embodiments, it
will be evident that various modifications and changes may be made
to these embodiments without departing from the broader spirit and
scope of the embodiments of the invention. Accordingly, the
specification and drawings are to be regarded in an illustrative
rather than a restrictive sense.
[0076] The methods described herein do not have to be executed in
the order described, or in any particular order. Moreover, various
activities described with respect to the methods identified herein
can be executed in serial or parallel fashion. Although "End"
blocks are shown in the flowcharts, the methods may be performed
continuously.
[0077] The Abstract of the Disclosure is provided to comply with 37
C.F.R. .sctn.1.72(b), requiring an abstract that will allow the
reader to quickly ascertain the nature of the technical disclosure.
It is submitted with the understanding that it will not be used to
interpret or limit the scope or meaning of the claims. In addition,
in the foregoing Detailed Description, it can be seen that various
features are grouped together in a single embodiment for the
purpose of streamlining the disclosure. This method of disclosure
is not to be interpreted as reflecting an intention that the
claimed embodiments require more features than are expressly
recited in each claim. Rather, as the following claims reflect,
inventive subject matter may lie in less than all features of a
single disclosed embodiment. Thus, the following claims are hereby
incorporated into the Detailed Description, with each claim
standing on its own as a separate embodiment.
* * * * *