4 Pharmacy and Dental Audit and Fraud Prevention

4 Pharmacy and Dental Audit and Fraud Prevention

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ESI Pharmacy and Dental Audit and Fraud PreventionLeiza McGrath, ManagerProvider Auditth4 Annual Pharmacy & Dental Outcomes ConferenceDid you know…• Industry* estimate: 3 - 10% loss to fraud and abuse • 2004 - Canadian Health Care expenditures (drug and dental) approximately $31.1 Billion*$933 Million - $3.1 Billion!*Industry – National Heathcare Anti-fraud Association*Source Canadian Institute for Health InformationOptimizing the value of drug and dental benefitsKey MessagesManaging risks is the key to a successful Audit programESI Canada is:• Focused on becoming the leader in Dental and Health Provider Audit• The leader in Pharmacy Provider AuditOptimizing the value of drug and dental benefitsSo what is ESI Canada doing?Optimizing the value of drug and dental benefits999999ESI Canada’s Fraud PolicyFraud Tip Fraud & Abuse HotlinePrevention and Detection StrategyFraud & AbusePrevention and Detection PhilosophyE-mail reporting systemFraud & Abuse Strategy: Key ComponentsAudit Mission StatementOptimizing the value of drug and dental benefitsRisk Management• Identify significant existing and potential risks• Define, classifying and communicating risk • Provide a structured risk assessment on an ongoing basisOptimizing the value of drug and dental benefits999Technology• Significant investment in technologyAutomate manual functionsQuestionable claims identificationEnsure protection of private ...

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ESI Pharmacy and Dental Audit and Fraud Prevention
Leiza McGrath, M anager
Provider Audit
4 th Annual Pharmacy & Dental Outcomes Conference
Did you know…
*
Industry estimate: 3 - 10% loss to fraud and abuse
2004 - Canadian Health Care expenditures (drug and dental) approximately $31.1 Billion *
$933 Million - $3.1 Billion!
*Industry – National Heathcare Anti-fraud Association *Source Canadian Institute for Health Information
Optimizing the value of drug and dental benefits
Key Messages
Managing risks is the key to a successful Audit program
ESI Canada is:
Focused on becoming the leader in Dental and Health Provider Audit
The leader in Pharmacy Provider Audit
Optimizing the value of drug and dental benefits
So what is ESI Canada doing?
Optimizing the value of drug and dental benefits
ESI Canada s Fraud Policy
9 Fraud & Abuse Prevention and Detection Strategy
9 E-mail reporting system
9 Audit Mission Statement
9 Fraud Tip Hotline 9 Fraud & Abuse Prevention and Detection Philosophy
9 Fraud & Abuse Strategy: Key Components
Optimizing the value of drug and dental benefits
Risk M anagement
Identify significant existing and potential risks
Define, classifying and communicating risk
Provide a structured risk assessment on an ongoing basis
Optimizing the value of drug and dental benefits
Techn ology
Significant investment in technology
9 Automate manual functions 9 Questionable claims identification 9 Ensure protection of private information
Optimizing the value of drug and dental benefits
Commi tment
10% of ESI Canada s staff are employed in the Provider Audit Department
Optimizing the value of drug and dental benefits
Industr y Initiatives
CHCAA – Canadian Healthcare Anti-Fraud Association
9 2005 Chairperson 9 Member of the Board of Directors and Executive committee 9 Chair the Dental Subcommittee
Optimizing the value of drug and dental benefits
Pharm acy/Drug – Abuse  and  Fraud
What are some of the current risks?
Billing for drugs not dispensed Overcharging Double doctoring Multiple Pharmacy use False or fabricated claims
Optimizing the value of drug and dental benefits
How d o we detect Pharmacy or Drug Abuse/Fraud?
Pharmacy data profiling
Patient verification letters
Physician verification letters
“Next day” audit review
“Desk Audit” review
On-site Audits
Cardholder Audits (coming in 2005)
Tips
Optimizing the value of drug and dental benefits