FORT WORTH, TX – In its work to reduce the cost of employee health care claims, the City of Fort Worth has excluded 24 suspect pharmacies from billing its plan, preventing $1.7 million in fraudulent payments to date, without member disruption.
For several years, Fort Worth officials have worked with SmartLight Analytics to find and remediate wasteful spending in its self-funded healthcare plan. In 2020, analysts added reviewing pharmacy claims and found suspect billing in this data, too.
“The patterns indicating abusive billing were clear. In one scheme, members were being prescribed broadly available creams and ointments by physicians that they hadn’t seen, and the prescriptions were filled at pharmacies hundreds of miles away from their home,” said Asha George, CEO and co-founder of SmartLight Analytics.
Working with Fort Worth’s pharmacy benefits manager (PBM), a plan was developed to address pharmacies where clear abusive patterns were noted in the data. The City has now suspended claims to 24 suspect pharmacies preventing an estimated $1.7 in fraudulent payments. It should be noted that the findings and actions were not disruptive for city employees. To date, not one employee complaint has been received, further confirming that employees were not aware these prescriptions were being filled under their pharmacy benefits.
“Whenever we find waste, fraud, or abuse for obvious reasons, we want to stop that as quickly as possible,” said Nathan Gregory, HR Director for the City of Fort Worth. “Everything we do within our health fund, we do with an awareness that ultimately, we are dealing with taxpayer funds. It’s our responsibility to provide good benefits to our employees but also in a sustainable manner so that our health plan is sustainable in the long-term.”
“We have been working with the City of Fort Worth to reduce its healthcare plan costs by regularly reviewing claims looking for fraud, waste or abuse that is adding to the City’s costs,” George said. “Since 2020, we’ve been able to return $3.5 million in savings back to the City’s plan from all of the medical and pharmacy overpayments.”
SmartLight Analytics combines the best inferential analytic models with a team of health insurance data and clinical experts to find fraud, waste, and abuse in self-funded employer healthcare plan claims data. SmartLight Analytics works with large employers to help them reduce healthcare spending by identifying and mitigating waste in claims. The process used by SmartLight Analytics uses proprietary models as well as clinical and investigative teams to minimize false positives. The team presents highly confident results and works directly with carriers to remediate costs.