Prescribing Digital Workflows to Mitigate Fraud Risk

September 24, 2020
3 Minute Read

When a Fortune 100 pharmaceutical company discovered some hospitals and clinics were exploiting a government program for additional revenue, they called on Veracity, an RGP company. Our team developed a case management system that would identify potential fraud and streamline claims adjudication. The result? A single source of truth that automates 82% of their previous workflow.

Our Fortune 100 biopharmaceutical client knows what it takes to distill something complex into something simple. Drug discovery, in and of itself, is like solving an intricate puzzle—starting on the edges, then testing each piece until it’s complete. And it’s the exhilaration of discovery that propels our client’s success in creating some of the most leading-edge products on the market.

But not all discoveries happen in the laboratory or under a microscope. They do, however, all begin with a clear problem. For our client, that problem arose when a program meant to help underserved populations save money on prescriptions slowly became a source for fraud.

Diagnosing Misuse of Drug Discounts

Like many drug companies, our client participates in government programs that lower prescription prices. One in particular, known as 340B, requires pharmaceutical companies to provide discounts on outpatient drugs to hospitals and clinics, known as “covered entities.” To be eligible for the program, healthcare  organizations must serve a large number of uninsured or underinsured patients. And while the savings are meant to be passed on to community care programs, some exploit the program as a source for new revenue.

To mitigate that risk, our client formed a fraud team tasked with identifying organizations that buy discounted drugs through the program, charge insurers the full price, and then pocket the difference. However, accessing the diverse data sources to determine the full scope of fraud was overwhelmingly complex.

Tethered to manual processes that required human intervention at every turn, cases were taking months or even years to close. With little time to proactively identify potential fraud, millions of dollars were left on the table.

Turning Months of Work into Days

Jen Jones, President of Brand Experience for Veracity, an RGP company, brings the perfect blend of empathy and execution to the job. Puzzling over problems to holistically understand issues and inspire scalable solutions, her enthusiasm for problem-solving can only be described as tireless. And when it came to creating a digital workflow that could turn months of work into days, Jen’s enthusiasm didn’t waver.

“We wanted to design an intuitive experience that could automate processes and proactively mine data,” says Jen. “The right system would represent a single source of truth that would allow our client to not only flag and investigate potential fraud, but also to track the progress of each case and perform predictive analytics.”

To do that, our team hosted virtual design sessions, mapping the entire current state process flow. Punctuated by complex decision trees and siloed workflows, the completed current state map spanned six phases with some 52 steps.

“That alone was actually the most helpful to the fraud team because they had no idea how big and cumbersome their process really was. Before that, they were unable to really articulate what they do,” Jen says.

“We wanted to design an intuitive experience that could automate processes and proactively mine data. The right system would represent a single source of truth that would allow our client to not only flag and investigate potential fraud, but also to track the progress of each case and perform predictive analytics.”

Collaborating with the fraud team, we designed a case management system that would automate 82% of their analysis and claims adjudication process. This solution also helped re-engineer workflows and automate case intake and tracking while providing valuable analytics and business metrics.

“We asked ourselves: What are the pages and requirements and things we need to build? How will someone work a case through the system? Then we identified user personas and their particular needs while designing a system that addressed each need,” says Jen.

The result is a digital case management system that automates 41 of the 52 steps in their workflow. By also designing proactive fraud targeting to automatically mine the company’s data lake and highlight red flags, we imagined a 100% new capability. In addition to saving the fraud team a heroic dose of time, the new system is expected to reveal an estimated $8 million in recovered funds in the first year alone.

“Our goal was to take something truly complex—with a lot of moving parts and processes—and leverage the right tools so that the data could do the heavy lifting. That way, the team could focus on what they’re good at: identifying and pursuing credible cases, not chasing down emails or vague leads,” says Jen.

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