Optum Rx is leaning on artificial intelligence as it looks to address costly fraud, waste and abuse in the pharmacy space.
The company is deploying real-time AI analytics that identify potential irregularities for auditors, who can then follow up with a pharmacist to address the issue. This process has historically been done manually, Optum said, and leaning on AI allows for quicker identification of risks and frees up auditors to focus on issues of the highest concern.
Mandy Rhubin, senior director of pharmacy network audit at Optum Rx, told Fierce Healthcare that fraud, waste and abuse (FWA) is on the rise across the healthcare system, and, given that costs are increasing across the board, there are plenty of opportunities for savings as well as to improve patient safety.
Optum notes a 2022 study that estimates pharmacy FWA costs the healthcare system $3.5 billion each year and can lead to issues like unnecessary refills or duplicate prescriptions.
"The traditional methods of identifying pharmacy FWA can be manual and time-consuming," Rhubin said. "And FWA is not stagnant. It continues to evolve, and we've got to stay on top of those issues now."
She said incorporating AI into the process allows for greater precision and accuracy and makes it easier for audit teams to stay ahead of the curve in terms of fraudulent behaviors. While something like a duplicate prescription can be accidental, intentional fraudulent actions include overbilling, billing for branded products when generics are dispensed or forged prescriptions.
Examples of the program in practice include a scenario in which Optum's AI identified that a patient was at risk for a double dose of their medication. The auditor was able to then quickly contact the pharmacist, who corrected the prescription and averted a potential adverse event for the patient.
In a second case study, Optum's platform flagged that a pharmacist had ordered an unusual quantity of a drug—more than 30 cases of a drug that was not in need. Once they were contacted, the pharmacist canceled the order, reducing unnecessary spend and inventory.
Rhubin added that the audit team has seen a 35% reduction in pharmacy audits that generated no FWA findings.
"Really, that helps the pharmacies, because it's reducing disruption and abrasion to pharmacies in our network," she said. "That way they can spend more time on their day-to-day activities and really focus on patient care."
Optum said these audits recover an average of $2 million for clients that deploy advanced pharmacy services. In the announcement, an Optum Rx client said that while the program is effective at identifying FWA, it "does not overwhelm the good actors."
The program is one of more than 1,000 AI solutions currently deployed across UnitedHealth Group. Rhubin said the team is focused on governance, and each final outcome is a decision made by a human.
"This is part of a broader commitment to apply AI, really, in responsible ways to improve the healthcare experience for everyone," she said.