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Prime Therapeutics is a privately owned pharmacy benefit manager that serves 23 Blue Cross and Blue Shield Plans and more than 28 million members across the US. With a commitment to making healthcare work better by helping people get the medicine they need to feel better and live well, Prime works with health plan owners and clients to support complete member health.

Part of Prime’s mandate is to control drug costs so that payers can continue to offer affordable benefits and to improve clinical and financial outcomes to help reduce the total cost of care. Both of these goals rely on a robust program to prevent fraud, waste and abuse (FWA) and Prime has a business unit dedicated to combating FWA.

But the company was using an inadequate system for tracking and managing its fraud investigations and this was preventing the team from reaching their goals. “We were using a shared drive,” says.Jo-Ellen Abou Nader, Vice President of Fraud, Waste and Abuse and Supply Chain Optimization. “It was not efficient… We had information spread across different areas and it was just difficult to find things and there was no process flow,” she says.

The Challenge

Workflow was disjointed and inefficient and it was difficult and time consuming to find information, track case activity and oversee the performance of cases. With 60 employees working in two coordinated teams assessing and investigating fraud, waste and abuse, the transition of cases from one team to the next was neither smooth nor transparent.

Oversight was limited to what supervisors could see in the shared documents, with no indicator of changes in case status. And with key information being tracked in spreadsheets, the team didn’t have easy access to case information or a strong reporting solution to conduct analysis on cases.

“There wasn’t a document repository that was used for any of the processes so that you could go and look at a case and see end-to-end all the documentation that supported that investigation as well as analysis,” says Korisa Matezevich, Senior Director, Supply Chain Shared Services. To answer basic questions about a case, you sometimes had to go through a time-consuming process of accessing multiple spreadsheets and emails, she adds.

In fact, satisfying a simple Request For Information (RFI) was challenging without a single source of information and audit trails. “They may ask for things two or three years down the road after we’ve done cases, and we have to be able to show them who did what on these cases because they may be summoned to testify,” says Abou Nader.

The Solution

Prime Therapeutics needed a secure, comprehensive case management system where all information was tracked, searchable and centralized. They needed a system that enabled a seamless case hand-off from the analysis team to the investigation team with both teams being able to share information to support the case.

Integration with the SAS fraud analytics tool was critical, so that information about potential fraud, waste and abuse could flow seamlessly into the case management system from the automated analytics platform. And the ability to link and relate cases was important so that investigators could collaborate to build the strongest cases possible.

Prime also needed a solution that was highly configurable. “We wanted to work with a vendor that was more flexible and not an out-of-the-box solution,” says Abou Nader. “We knew that we had to change workflow to make it fit what we needed from an investigation standpoint. We also wanted a tool that clients could potentially log into from a portal, because we are trying to be transparent with our clients’ SIU units,” she says.

Prime already had six clients using Case IQ, so they knew the system was a good fit for their needs. After assessing several vendors, Prime Therapeutics chose Case IQ’s health care fraud case management solution.

“By far [Case IQ] has been my favorite vendor to work with, which is a big feat, because sometimes those things can be difficult,” says Matezevich. “What stood out was that [Case IQ] had a very smooth process to provide tangible feedback on what they understood the requirements were they were delivering so they could mitigate any translational errors in those requirements very quickly. They took a lot of time to understand what we were doing. There were points during the process where they were able to make a suggestion such as ‘I think you are trying to accomplish this and we can make a recommendation to help you solve this based on other solutions that we’ve put forward for other clients’,” she says.

The Result

Today, the FWA team at Prime appreciates the seamless, logical workflow of their new Case IQ solution. All tasks and activities are managed in one system, from the identification of potential fraud using the integrated SAS analytics platform through the assignment, investigation and data and trend analysis. The web-based platform is secure and reliable and ensures that case information is accessible from anywhere.

Case IQ’s intuitive interface helped ensure new users felt comfortable using it, resulting in quick onboarding. “I’ve been very impressed with [Case IQ] from the beginning and how fast we were able to set this up,” says Abou Nader.

When an analyst enters information, automatically generated to-dos lead them through the process to help them complete all the steps. Seamless workflow rules assist the progression of cases from analysts to investigators and through the investigation process. Supervisors appreciate the visibility into the progression of cases, with a complete history of all activities, time stamps, interviews and notes.

Case linking is particularly valuable to investigators and helps the team identify relationships among cases. “When reviewing the information, there can be instances where you’re not aware these things are interrelated. When you can put those pieces together you see a much bigger story and potentially a much larger referral we send to our clients and identify an impactful case for them,” says Matezevich.

“From a compliance perspective, we are able to mitigate losing track of an RFI or not responding in a reasonable manner,” says Matezevich. She adds that the ability to designate cases as confidential and to protect legal information has introduced another level of enhanced compliance.

But it’s the increased efficiency that has been the most obvious difference for the Prime FWA team. “I think we are able to do twice the amount that we could have historically done,” says Matezevich. “Even the amount of leads that we are able to send through to the investigations team. I’m not sure we’d be able to keep up with that pace if we didn’t have a platform.”

Abou Nader estimates a 20 to 25 per cent efficiency gain in her team, resulting from the improvements in structure, workflow, reporting capabilities and management oversight. “I think we’ve made some strong progress in just setting up structure for this organization and a solid foundation to continue to build on from that,” she says. “So I’ve been very impressed.”

And the numbers speak for themselves. With 721 cases referred by August of 2019, Prime’s fraud, waste and abuse team had achieved $56 million in savings to clients through referrals (both preventive and recovered).