Systems and methods for identifying fraud and abuse in prescription claims
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United States of America Patent
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N/A
Issued Date -
N/A
app pub date -
May 16, 2003
filing date -
May 16, 2002
priority date (Note) -
Abandoned
status (Latency Note)
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Abstract
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 utilizes a compilation of expert rules and profiling engine methodologies to determine the likelihood that a transaction is the result of fraudulent or abusive behavior. The fraud scoring engine 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 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.
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