From the September 2016 issue of HealthCare Business News magazine
• Rate of “new billing."
• Reversal rate (very high and very low).
• Percentage of member copays.
• Average ingredient cost.
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• Average paid subscription.
• Average number of prescriptions per member (stratified by age).
• Percentage of controlled substances.
• Average dollars paid per member.
By highlighting the results on the dashboard, it becomes easier to identify overall trends. It is also easier to identify pharmacies that may require corrective interventions such as pending (holding) claims or withholding payment, as well as those that require an on-site visit or other more severe actions. It is similar to finding retail stores claiming excessive losses that would be otherwise difficult to discover.
The importance of flexibility
As in most industries, 90 percent of FWA analytics in health care tend to be the same. The other 10 percent, however, are often critical to an individual organization — so it is crucially important that the analytics being used have the flexibility to meet those more specialized demands.
Retail pharmacies, for example, may want the ability to configure the analytics to compare the performance of different locations to those of its competitors to determine if a one- or two-week spike in controlled substances is specific to its organization, or is being seen by other retailers as well. This ability to adjust what is being measured and how the information is being displayed, is helping health payers and PBMs focus their efforts where they will yield the greatest benefit and ROI, while at the same time limiting wasted effort chasing false positives. This is a far more effective approach than trying to investigate every potential incident.
Overcoming the curse
The information age has accelerated the pace and reach of business to drive greater profitability. But it has also opened organizations to greater risks. Next-generation analytics that are able to automatically identify significant deviations from the norm, and then apply additional logic or parameters to separate the concerning from the merely odd, can remove the curse of the monkey’s paw from the vulnerabilities inherent in its data today. And that will help keep organizations from increasingly falling victim to fraud, waste and abuse of prescription drugs.
About the author: Rena Bielinski, PharmD, AHFI, is senior vice president and chief pharmacy officer at SCIO Health Analytics, an organization dedicated to using health care analytics to improve clinical outcomes, operational performance and business results. Dr. Bielinski has more than 20 years of experience in managing clinical and pharmaceutical data integrity, and is an accredited health care fraud investigator.Back to HCB News
