As pharmacy expenditures rise, pharmacy FWA continues to be a prevalent issue for both commercial and government payers. RxShield is fully integrated with PreShield, PostShield, QueryShield, and CaseShield empowering Healthcare Fraud Shield customers to be able to:
- Identify prescription drugs improperly billed based on company policies and guidelines.
- Demonstrate abusive patterns of prescription use by members; such as obtaining early refills, pharmacy and doctor shopping and more.
- Detect prescribers providing medications outside the standard of care.
- Peer comparison of pharmacies for aberrancies such as excessive use of override codes, high volume of brand drugs, suspect number of controlled substances and more.
- Conduct cross-claim analysis between pharmacy and medical claims to identify potential double billing as well as diagnoses that do not support the medications prescribed.
- Easily create detailed customized analysis reports using both pharmacy and medical data.
- Keep investigators up-to-date with industry trends as new pharmacy, member and prescriber alerts are added quarterly.
Additional HCFS Products and Services
An integrated fraud, waste, and abuse solution that utilizes unique and proprietary data sources to maximize Return on Investment (ROI) and achieve superior results.
An AI-driven anomaly detection platform that identifies risk vectors from emerging schemes and behaviors.