SYSTEMS AND METHODS FOR IDENTIFYING FRAUD AND ABUSE IN PRESCRIPTION CLAIMS

摘要

Systems and methods permit the identification of fraud and abuse in electronic prescription transactions by intercepting and analyzing prescription claims to determine the likelihood that a claim is fraudulent. A fraud scoring engine (122) utilizes a compilation of expert rules (104, 134, 105) and profiling engine methodologies to determine the likelihood that a transaction is the result of fraudulent or abusive behavior. The fraud scoring engine (122) assigns a fraud score to rate the probability that a transaction is fraudulent in nature. The fraud score is compared against payer-defined business rules (105, 134) to determine if a claim is rejected as fraudulent. A fraud management interface enables payers to view a rejected claim and the reasons why a claim is rejected so that the reasons can be explained to a pharmacist, should the pharmacist contact the payer.