Optum Rx relies on artificial intelligence to combat costly fraud, waste, and abuse in the pharmacy space.
The company has implemented real-time AI analysis that helps auditors identify potential fraud, and allows auditors to follow up with pharmacists to address issues. Optum says this process has traditionally been done manually, but using AI will help identify risks more quickly and allow auditors to focus on the issues of greatest concern.
Mandy Rhubin, Senior Director of Pharmacy Network Audit at Optum Rx, told Fierce Healthcare that given that fraud, waste, and abuse (FWA) is on the rise across the health care system and costs are increasing across the board, there are many opportunities for savings as well as improved patient safety.
Optum points to a 2022 study that estimates that pharmacy FWAs cost health systems $3.5 billion annually and can cause problems such as unnecessary refills and duplicate prescriptions.
“Traditional methods of identifying a pharmacy’s FWAs can be manual and time-consuming,” says Rhubin. “And FWA is not stagnant; it continues to evolve, and we need to stay on top of these issues now.”
He said incorporating AI into the process will improve precision and precision, making it easier for audit teams to stay ahead of the curve when it comes to fraud. While duplicate prescriptions can be accidental, intentional fraud includes overcharging, charging for brand-name products when dispensing generic drugs, and falsifying prescriptions.
A real-world program example includes a scenario where Optum’s AI identified that a patient was at risk of taking twice the medication. The auditor was then able to immediately contact the pharmacist, who corrected the prescription and avoided any possible adverse events for the patient.
In the second case study, Optum’s platform alerted the pharmacist that he had ordered an unusual amount of medication. That means I ordered over 30 cases of drugs I didn’t need. Once contacted, the pharmacist canceled the order, reducing unnecessary spending and inventory.
Rhubin added that the audit team saw a 35% reduction in pharmacy audits that did not show FWA findings.
“Really, this is helpful for pharmacies because it reduces confusion and fatigue for pharmacies in our network,” she says. “This allows them to spend more time in their daily activities and truly focus on patient care.”
Optum says these audits can recover an average of $2 million for its advanced pharmacy services customers. Optum Rx customers said in a statement that while the program is effective at identifying FWAs, it “doesn’t overwhelm benevolent attackers.”
The program is one of more than 1,000 AI solutions currently deployed across UnitedHealth Group. Rubin said the team is focused on governance and that the final outcome is entirely based on human judgment.
“This is part of a broader effort to apply AI in a real and responsible way to improve the healthcare experience for everyone,” she said.
