We have developed state of the art detection and resolution/auditing systems for pharmacy claims.
ANALYSIS – COPs System ™
The Cluster Optics Process system is a proprietary software program that allows your health plan OR PIC to quickly analyze high volumes of claims data to identify inappropriate relationships between physicians, pharmacies and patients which leads to fraudulent claim detection.
Using Big Data (internet and purchased data) and real-time analytics, the COPs investigation tool become more powerful to uncover fraud “rings” – “patients” (whose identity may be stolen), prescribers and pharmacists working together.
After the discovery process, auditors recover on claims processed incorrectly through a desk audit process that can be done by PIC or your staff. Trained investigators can pursue onsite covert and overt investigators for preparation for litigation and restitution.
AUDITS – CARs System ™
CARs (Claim Audit Recovery System) is a companion software-as-a-service product to COPs. CARs automatically transfers claims from COPs for auditing:
- CARs provides a quick and secure method of obtaining claims audit documentation from pharmacies.
- Claims data and the visual documentation provided by the pharmacies is matched and easily reviewed by auditors, reducing audit error.
- CARs automatically updates audit dashboards and provides up to the minute status of audit workload.
- CARs re-ingests data back into COPs for machine learning.
INVESTIGATION
PIC conducts both overt and covert investigations to aid in the prosecution and recovery of health care fraud. Covert techniques include video surveillance, research and data gathering. Overt techniques include audits, interviewing and documentation of key evidence.
For hospital clients, we perform physical assessments of facilities to minimize diversion (theft) from in-patient and out-patient pharmacies. We can also investigation potential and real staff diversion and impairment to ensure that hospitals do not suffer from the liability of impaired staff or the public relations issues associated with diversion.
RECOVERY
POS recovers any amounts owed to plan sponsors as a result of our field work. In limited situations, pharmacies or physicians further investigated by law enforcement.