Pharmacy Investigators & Consultants (PIC) is the only pharmacy investigation firm owned by a Licensed Private Detective with over 35 years of health care experience.
In January 2019, Pharmacy Outcomes Specialists rebranded to become a powerful force in the pharmacy benefits arena. Combining 23 years of employee benefit consulting experience, with leading edge software programs and investigation services aimed at detecting and recovering dollars lost to fraud, waste and abuse in pharmacy networks, we became Pharmacy Investigators and Consultants (PIC), a woman-owned business enterprise (WBE).
Founded in 1996, Pharmacy Outcomes Specialists was one of the most experienced consulting firms having performed over 1,00 pharmacy benefit audits and reviewing the accuracy of over 200 million pharmacy claims. Our experience encompassed managing large complicated audits of Medicare Part D programs and audits of Pharmacy Benefit Managers (PBMs) for compliance to plan terms and government regulations. POS also served the broader pharmacy benefits industry through hosting our annual pharmacy benefits educational conference. Our consultants and partners are a unique group of pharmacists, pharmacy technicians, accountants, financial analysts, attorneys and government program specialists.
During the last five years, Pharmacy Outcomes Specialists developed state of the art computer systems that score and audit claims for potential fraud. COPs (Cluster Optics Process), based on criminological theory, automatically ingests millions of claims a month and scores claims for potential fraud merging claims data with Big Data. CARs (Claim Audit Recovery System) is our communication portal with chains and independent pharmacies and allows for cost effective auditing of claims identified by COPs. When the auditing process is complete, CARs sends COPs audited data for machine learning. We now have three major pharmacy benefit administrators utilizing these systems. As a result, we have expanded our scope of services, rebranded as Pharmacy Investigators and Consultants and have become a Women Owned Business (WBE) enterprise.
We are currently developing P3, a Pharmacy Procurement Portal, where the industry can see contract terms and clients can run data to test if their current pharmacy benefit financial performance guarantees are market competitive. This opens up a whole new layer of transparency in the industry. Pay a small fee, run your data and no longer are you beholden to brokers or consultants that do not have your interests in mind.
Since 1996, our mission has been clear and unwavering: To provide plan sponsors with expert pharmacy benefits advice, unbiased from any industry influence, that helps lower costs and increase the health and productivity of the membership.
When Pharmacy Outcomes Specialists started in 1996, pharmacy costs were $200 per member per year. There were no consulting firms at that time specializing in just pharmacy benefits consulting. But Pharmacy Outcomes Specialists founders realized with the United States workforce growing older and technology advancing, prescription drugs were going to be more important than medical costs in terms of employee productivity, member satisfaction and bottom-line profits. By 2019, drug cost per member per year average over $5,000, with retiree costs as much as $10,000 per year.
At the same time drug costs have increased, publicly traded pharmacy benefit managers – the middlemen between pharmaceutical companies and plans sponsors– have returned significant profits for their shareholders. Many have merged until there are “the Big Three” which has reduced plan sponsors’ ability to negotiate. Profits have come, in part, by creating margins between what pharmacies are reimbursed and what plan sponsors pay for the same prescription order and carving up drug rebates into dollars retained by the PBM and dollars that the PBM elects can be passed back in portion to the plan sponsor.
The convergence of complex pricing rules, advanced computer technology, expensive lifesaving specialty drugs and a blend of specialty drugs/brand/generic/over the counter/behind the counter product array results in significant challenges to manage costs and maintain member satisfaction and loyalty for most pharmacy benefit managers.
Pharmacy Investigators and Consultants is uniquely positioned to assist plan sponsors and pharmacy providers with expert advice. Whether you are a mid-sized employer seeking a better PBM relationship, a large health insurer needing to assure your Medicare Part D plan complies with regulations or a managed care provider wanting to audit pharmacies in the network, Pharmacy Investigators and Consultants can help.
Pharmacy Investigators and Consultants maintains independence and avoids any conflict of interest in part by how we provide consulting services. We are paid by our clients on a flat fee basis. Every project has a quoted price that Pharmacy Investigators and Consultants does not exceed unless the scope of the project changes. We do not retain commission or any monies from PBMs, unlike other consultants. Our obligations are solely to our clients to get the job done timely and accurately and without industry bias.
Learn more about how PIC experts use criminological theory to solve health care fraud dilemmas.