Fraud, abuse, and error detection in transactional pharmacy claims

A computer-implemented method for processing benefits payment claims for prescription medicine, comprising operations of:

• receiving pending pharmacy benefits payment claims submitted for payment by a pharmacy benefits claims payor, each claim specifying a patient;
• for each claim and its specified patient, performing operations comprising:
• performing computer-driven statistical analysis of predefined aspects of one of the following in relation to a compiled history of past claims paid by one or more pharmacy benefits claims payors:
• claims history for the patient, the claim, medical history of the patient;
• generating an indicator of predicted legitimacy by scoring results of the statistical analysis;
• providing an output of at least one of the following:
• the indicator, payment advice prepared by applying predefined criteria to data including the indicator.

A computer-driven apparatus to process payment claims for prescription medicine, comprising:

• an interface receiving pharmacy benefits payment claims submitted for payment by a pharmacy benefits claims payor, each claim specifying a patient-drug combination;
• a computer-driven analysis module programmed to perform operations for each claim, comprising:
• performing computer-driven statistical analysis of predefined aspects of a claims history for the specified patient-drug combination in relation to a history of claims paid by the pharmacy benefits claims payor involving a multiplicity of different patients and drugs;
• generating an indicator of predicted legitimacy by scoring results of the statistical analysis;
• providing an output of at least one of the following:
• the indicator, payment advice prepared by applying predefined criteria to data including the indicator.

A computer-driven apparatus to process payment claims for prescription medicine, comprising:

• interface means for receiving pending pharmacy benefits payment claims submitted for payment by a pharmacy benefits claims payor, each claim specifying a patient;
• computer-driven analysis means for performing operations for each claim and its specified patient, comprising:
• performing computer-driven statistical analysis of predefined aspects of one of the following in relation to a compiled history of past claims paid by one or more pharmacy benefits claims payors:
• claims history for the patient, the claim, medical history of the patient;
• generating an indicator of predicted legitimacy by scoring results of the statistical analysis;
• providing an output of at least one of the following:
• the indicator, payment advice prepared by applying predefined criteria to data including the indicator.

A computer-driven apparatus to process prescription payment claims, comprising:

• at least one interface to receive pharmacy benefits payment claims submitted for payment by a pharmacy benefits claims payor, each claim including specification of a patient;
• first digital data storage containing a compiled history of past claims paid by one or more pharmacy benefits claims payors;
• second digital data storage containing multiple schemas each defining a condition as to one of the following:
• patient claims history, payment claim, patient medical history;
• a metrics engine programmed to compute metrics by applying the schemas to data of at least one of the following in conjunction with a patient:
• patient claims history, payment claim, patient medical history, bulk data;
• a baseline engine to receive metrics computed for substantially all patients in the compiled history and produce baseline data comprising a statistical analysis of the received metrics in relation to the bulk data;
• scoring engine programmed to process a claim received at the interface by performing operations comprising:
• receiving metrics computed for a patient specified by the received claim;
• statistically analyzing the received metrics against the compiled history;
• generating an indicator of predicted legitimacy by scoring results of the statistical analysis;
• providing an output of at least one of the following:
• the indicator, payment advice prepared by applying predefined criteria to data including the indicator.

A computer-driven apparatus to process payment claims for prescription medicine, comprising:

• an interface receiving pending pharmacy benefits payment claims submitted for payment by a pharmacy benefits claims payor, each claim specifying a patient;
• a computer-driven analysis module programmed to perform operations for each claim and its specified patient, comprising:
• performing computer-driven statistical analysis of predefined aspects of one of the following in relation to a compiled history of past claims paid by one or more pharmacy benefits claims payors:
• claims history for the patient, the claim, medical history of the patient;
• generating an indicator of predicted legitimacy by scoring results of the statistical analysis;
• providing an output of at least one of the following:
• the indicator, payment advice prepared by applying predefined criteria to data including the indicator.