Welcome to PIC!

Welcome to the new Pharmacy Investigators and Consultants web page. If you made it here, you are probably interested in ensuring that your retail or hospital pharmacy is fraud and drug diversion free or as a pharmacy benefit manager (PBM), the claims you process are legitimate and appropriate for the patients your clients cover. You may be a health litigator needing an expert who understands the complexities of the pharmacy delivery process. Bottom line, we are a group of seasoned professionals that help keep fraud out of the pharmacy setting.

Health care fraud is a topic of the news almost every day, unfortunately.   We were on top of the Valeant/Philidor scandal long before it hit the news. We were aware of phantom prescriptions being dispensed and alerted our clients, based on the data provided by our clients. We are now fighting with some of the larger PBMs who should have observed the same thing we did and eliminated Philidor from the network. However, when PBMs take hidden spread on phantom claims, the fraud and misaligned intensions increase exponentially. Our scientific approach that combines criminological theory with data analytics is how we discovered this fraudulent situation.

Health care has become incredibly complex over the last decade and more and more expensive. This combination of higher costs (some therapies are over $1 million per patient) and greater complexity due to the lack of transparency has made providing health care a difficult endeavor. In addition, more and more Americans are covered through Medicare Part D, which started in 2006 and the Affordable Healthcare Act (ACA) which started in 2010 (some parts being phased in over the last five years). An unintended consequence of the ACA is that as more providers more to electronic medical records (EMR) those records are easier to steal. What once took up an entire room of a medical practice can now be stored on a hard drive, and lifted by motivated offenders working in a pharmacy or medical practice.

Here is what we do:

• We assist hospital pharmacies ensure that drugs are not leaving the hospital through staff/vendor diversion (stealing) through better inventory management and through CPTED (crime prevention through environmental design) methods such as biometrics, video and camera surveillance and through improved staff investigation procedures. We can also ensure that inventory is managed properly and efficiently and to maximize third party reimbursements.

• We assist health plans and Pharmacy Benefit Managers (PBMs) detect fraudulent claims through our sophisticated COPs program. COPs visually and quickly sorts through thousands of claims to identify inappropriate relationships between physicians, pharmacies and patients – the three main co-conspirators in pharmacy fraud. Social media investigations are conducted and added to visually stunning reports for SIU investigators. COPs can even alert members or investigators through text messaging that a problem has occurred through the claims adjudication problem, stopping claims before drugs even leave the pharmacy.

• We assist pharmacy with regulatory requirements. There are many agencies that a pharmacy “reports” to including the DEA, the State Board of Pharmacy, OIG and HRSA, state laws and local ordinances. PIC ensures that pharmacies are up to date on all of the required legal requirements, for facilities as diverse as National Football League training facilities to school pharmacies to hospital and mail order pharmacies to medicinal marijuana dispensing facilities.

I am sure the next decade will be challenging to pharmacies and we stand ready to assist with pharmacy security, management and claims adjudication needs. Join us in the fight against fraud or just rest easy that your pharmacy is well protected. Your patient’s safety is depending on it.