Blue Plan partnership takes center stage at the SIU Forum

The collaborative Blue + Prime investigative approach has resulted in 40 percent of Prime’s cases getting picked up by law enforcement. In October, Prime highlighted this success and future FWA innovations at its second annual Special Investigative Unit (SIU) Leadership Forum in Nashville.

Leaders from Blue Plan clients and Prime’s investigative teams attended this information sharing and networking event. Through presentations, case studies and small-group breakout sessions, forum participants strategized about continued partnership opportunities and how to maximize our unique business model to combat fraud.

Anne Mack, senior director of pharmacy audit and fraud, waste and abuse reflected on the forum as a key driver in high scores from a recent client satisfaction survey where clients shared appreciation of the team’s honesty, transparency, innovation and collaboration.

“We love to meet face to face with the SIU health plan leaders that we deal with daily. They are part of our extended team,” Jo-Ellen Abou Nader, vice president of fraud, waste, and abuse and supply chain optimization, says. “I’ve been in the PBM industry for 20 years and I’ve never seen such great partnership with clients. Clients love how we continue to push forward from an innovation standpoint. We push them to move forward as well.”

Prime’s advanced analytics platform uses integrated medical and pharmacy data

Prime uses a highly effective, two-tiered approach to identify and eliminate fraud, waste and abuse in all forms. Through advanced analytics, powered by SAS – an artificial intelligence vendor that powers data to identify fraud risk – Prime finds bad-acting pharmacies, prescribers and members that add waste and cost to the system.

In its first year deploying the enhanced fraud, waste and abuse (FWA) program, Prime achieved an overall savings for its health plan clients of $279 million. This savings included recovering $51 million recovered through audits and investigations and $228 million of cost avoidance through audits and investigations while focusing on the core areas of retrospective analysis, potential erroneous spending and pharmacy examinations.