Using Data to Identify Fraudulent Claims
Pharmacy Reimbursement of $26,000
Challenge
- During our quarterly review of claims data in RxMart, Excelsior Solutions noticed some unusually high prices on a handful of prescriptions
- One member was filling all prescriptions at the same pharmacy at a location outside of member’s living area
Solution
- Excelsior Solutions brought this concern to the PBM’s attention
- Pharmacy was processing fraudulent claims
- Pharmacy closed before PBM could remove it from the network for fraudulent practices
Client Win
- $26,000 reimbursed to client for fraudulent claims that would have gone unnoticed without RxMart’s ongoing monitoring
