Life Altering Analysis to Catch a Predatory Pharmacy
Customer Company Size
Mid-size Company
Region
- America
Country
- United States
Product
- Alteryx
Tech Stack
- SQL
- SOAP API
Implementation Scale
- Enterprise-wide Deployment
Impact Metrics
- Cost Savings
- Productivity Improvements
Technology Category
- Analytics & Modeling - Big Data Analytics
Applicable Industries
- Healthcare & Hospitals
Applicable Functions
- Procurement
Use Cases
- Fraud Detection
- Predictive Quality Analytics
Services
- Data Science Services
About The Customer
SCAN is a non-profit Medicare Advantage organization serving California. The organization serves approximately 200,000 members, largely in the Southern California region. The Centers of Medicare and Medicaid require health plans to have a fraud, waste, and abuse program. SCAN achieves this through the Special Investigations Unit. This unit investigates allegations that might have an adverse financial or compliance impact on members or the program. The team is responsible for identifying and addressing issues that could potentially harm the organization or its members.
The Challenge
In early 2017, SCAN, a non-profit Medicare Advantage organization serving California, started receiving reports from members about receiving unwanted Lidocaine ointments by mail. This scheme had started affecting the industry in 2015, but had not yet impacted SCAN at a significant scale. The challenge was to identify the source of this scheme and stop it from further affecting the members and the organization financially. The Special Investigations Unit at SCAN was tasked with investigating these allegations that might have an adverse financial or compliance impact on members or the program. The team had to figure out the chances of one member being served by many pharmacies, dozens of members going to the same pharmacy outside California, every patient getting the same high quality, and several pharmacies sharing the same address.
The Solution
The Special Investigations Unit at SCAN used Alteryx, a data analytics platform, to investigate the allegations. The team used the network analysis tool in Alteryx to identify abnormal behavior and prioritize resources and investigations. The tool helped them visualize normal behavior versus abnormal behavior and identify more pharmacies with similar practices. The team also used Alteryx to monitor prescriptions for 1,000 affected members weekly for the same dispensing patterns from new pharmacies and adjust for new schemes. They also used Alteryx for spatial analysis, mapping distance and drive time for potential drug-seeking members and those receiving prescriptions or services from out of area. They also integrated with third-party data sources, retrieving data from regulatory bodies.
Operational Impact
Quantitative Benefit
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