Fraud, Waste & Abuse Management

Combating Fraud, Waste and Abuse in the Prescription Drug Benefit Plans is becoming a priority for both public and private insurance programs battling prescription drug fraud and abuse estimated as high as $22 billion in the United States. A paradigm change is imperative in fighting this epidemic with pro-active analysis for new claims as well as retrospective trending of old claims.

In a traditional pharmacy claims processing environment detection systems have been unable to answer the question ‘Should we pay that claim?”. HCL’s solution focuses on enhancing the fraud, waste and abuse discovery process through improved detection transparency in claims processing from two distinct segments: Real time or near real time predictive analysis on live claims and Trend analysis on paid medical surgical and drug claims history. The HCL solution empowers stakeholders.

• Improving Rx Claim payment accuracy and increase in annual profitability
• Providing cost-effective platform for greater financial return
• Building a secure environment that discourages future abuse