Methods and systems for drug purchase validation

Abstract

Methods and systems for drug purchase validation are described. In an example embodiment, drug sale data is accessed from a prescription drug wholesaler regarding prescription drugs sold to the pharmacy by the prescription drug wholesaler during a period of time. A number of units of a prescription drug sold to the pharmacy are determined based on the drug sale data during the period of time. Pharmacy claims data over the period of time is accessed, where the pharmacy claims data reflects a plurality of adjudicated claims, and the plurality of adjudicated claims are a plurality of claims that were submitted for adjudication by the pharmacy during the period of time. A number of units of a prescription drug associated with the plurality of claims submitted during the period of time by the pharmacy for adjudication are determined based on the pharmacy claims data. The number of units of the prescription drug associated with the plurality of adjudicated claims that were submitted for adjudication by the pharmacy is compared with the number of units of the prescription drug sold to the pharmacy. A determination is then made as to whether a discrepancy exists based on the results of the comparison. Additional methods and systems are disclosed.

Description

CROSS REFERENCE TO RELATED APPLICATION[0001]This application claims priority to and is a continuation of U.S. patent application Ser. No. 13 / 340,809 filed on Dec. 30, 2011, entitled “Methods and Systems for Drug Purchase Validation” the entire disclosure of which is incorporated herein by reference.FIELD[0002]The field relates to fraud detection, and more particularly to electronic verification of prescription drug sales by a pharmacy.BACKGROUND[0003]Pharmacy benefit managers (PBMs) offer prescription drug benefit plans that allow members to have drug prescriptions filled at various in-network pharmacy locations. These locations may include retail locations, mail locations, or both retail and mail locations.[0004]When a physician writes a prescription for a patient, the patient takes the prescription to a pharmacy to have the prescription filled. The pharmacy submits the prescription to the PBM for adjudication, fills the prescription, and accepts a co-pay from the patient. Once the...

AI Technical Summary

Problems solved by technology

By analyzing this data, the purchase validation device may determine that a pharmacy has reportedly filled prescriptions for more drugs than it has purchased, which may indicate fraud.

However, patients, doctors and / or pharmacies may attempt to abuse the system.

Submitting relatively few false claims for adjudication can result in sizeable payments from the PBM to the pharmacy.

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