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Focused on Fighting FWA

MedImpact helps Canadian plans stay ahead of dynamic fraud, waste and abuse

A family physician in Montréal makes an honest mistake that leads to a billing error. Inefficiencies at a local Toronto hospital result in wasteful diagnostic and laboratory tests. A network of U.S. retail pharmacists conspires in a multimillion dollar billing scheme involving HIV drugs and kickbacks.

Collectively, fraud, waste, and abuse (FWA) is a worldwide crisis that costs an estimated at least $260 billion — or 6% of global healthcare spending annually, according to the Global Healthcare Anti-Fraud Network. That’s equivalent to stealing the GDP of a country the size of Finland every year.1  

In the U.S. alone, other industry sources report the adverse impact of FWA range from a conservative $80 billion to staggering $272 billion. Even worse, only a mere 5% of these losses are recovered.2  

Likewise, FWA occurs daily in Canada and costs the system hundreds of millions of dollars annually. The Canadian Life and Health Insurance Association (CLHIA) estimates the number of fraudulent claims in Canada range from 2% to 10% — meaning between $600 million and $3.4 billion is being stolen annually.3

Combatting FWA in today’s dynamic healthcare environment requires advanced analytics and data mining, smarter case management, and more tailored clinical interventions.

In response to this global challenge, MedImpact brings bold and innovative thinking to help overcome complex FWA challenges. To help clients gain more control over FWA, MedImpact has developed an integrated bundle of advanced analytic and clinical services that leverages machine learning to combat potential FWA —helping save clients millions of dollars every year.

As a global thought leader with proven solutions and success in the United States, MedImpact is now changing PBM services in Canada and abroad. Today, our international division provides pharmacy benefits to plans and members worldwide.

Partnering with SEB to Combat FWA

In Canada, MedImpact has established a strategic marketing business relationship with Smart Employee Benefits Inc. (SEB) to offer MedImpact’s PBM solutions alongside SEB’s FlexPlus benefits processing ecosystem. The combined offering will provide SEB’s clients with the opportunity to benefit from MedImpact’s PBM solutions that target FWA. This includes holistic and coordinated data analytics that enhance plan sponsors’ abilities to better identify and manage potential FWA.

Read the full “Focused on Fighting FWA” white paper to see how MedImpact’s dynamic approach to FWA is helping plans in Canada and how we’re partnering with SEB to combat it.

Our team then immediately began an investigation into these claims and identified several pharmacies that were responsible for submitting a disproportionate number of diabetic footbath claims.

Want to learn more about how MedImpact helps clients and members reduce costs? Download "An Integrated Approach to Combatting Dynamic FWAto see how MedImpact helped six U.S. health plans save more than $18 million with advanced FWA solutions. 

1   Global Health Anti-Fraud Network: https://www.ghcan.org/global-anti-fraud-resources/the-health-care-fraud-challenge
2  The Economist & PSG: https://www.economist.com/united-states/2014/05/31/the-272-billion-swindle; https://www.psgconsults.com/blog/remedy-the-dangers-of-prescription-fraud-waste-and-abuse
3 Canadian Life and Health Insurance Association: https://www.clhia.ca/; Canadian Medical Association Journal: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3537805/

 

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