MAC + UPIC + state Medicaid + commercial payers

Retail Pharmacy Fraud Detection

MCO retail-pharmacy fraud: prescriber-pharmacy chain analysis, opioid co-fill patterns, brand-vs-generic dispensation anomalies, member benefit conflicts.

The retail pharmacy fraud landscape

Understanding the scope and impact of retail pharmacy fraud

Retail pharmacy fraud, particularly within the Medicare Part D and Medicaid subsets, presents a significant challenge for healthcare payers and regulators. This section delves into the landscape of retail pharmacy fraud, highlighting the complexities and the need for robust detection mechanisms.

The Total Addressable Market (TAM) for retail pharmacy fraud detection within Medicare Part D and Medicaid is substantial, underscoring the critical need for effective solutions.

How JIL closes it

JIL Sovereign's approach to combating retail pharmacy fraud

JIL Sovereign addresses retail pharmacy fraud through a comprehensive analysis of prescriber-pharmacy chains, opioid co-fill patterns, brand-vs-generic dispensation anomalies, and member benefit conflicts. Our platform leverages advanced data analytics and cross-source datasets to identify and mitigate fraudulent activities.

By integrating 20 distinct attestation checks, JIL Sovereign ensures a thorough examination of retail pharmacy claims, providing payers with actionable insights and Court-Ready Evidence Bundles (CREB) for legal proceedings.

Opioid co-fill patterns

Identifying opioid co-fill patterns to detect fraud

One of the critical components of JIL Sovereign's fraud detection strategy is the analysis of opioid co-fill patterns. By examining the co-dispensation of opioids with other controlled substances, our platform can flag suspicious activities that may indicate fraud.

This targeted analysis helps in identifying potential prescriber-pharmacy collusion and ensures that opioid prescriptions are legitimate and necessary, thereby protecting both patients and payers from fraudulent schemes.

Pricing

Transparent and competitive pricing for retail pharmacy fraud detection

Pricing -- Fraud Pillar Standard

One model. Bottom-line aligned.

Retroactive scan
one-time, scoped to volume
4-year minimum lookback. Builds the base dataset. Proves the closed-loop economics before the flat-fee leg starts.
Flat fee
12.5% of disclosed PI spend
Annual, capped. Covers nightly T1 + AVA + T2 + CREB(TM) generation. Below the industry-standard 15 to 25% SIU contingency.
Contingency
10% of net cash recovered
Performance-aligned. Fires only on actual recovered cash, net of MAC appeal, settlement, and pursuit. Outside counsel runs 33%.
90-day pilot
$1M all-in, asymmetric downside
If Day 90 deliverables miss, the $1M converts to a 6-month platform credit and contingency drops from 10% to 7.5%. No other vendor in PI takes pure downside on the math.

Pricing anchored to public 10-K Schedule H disclosures + CMS PERM 2024. UHG-scale case study available at /products/mco-flat-fee.

90-day pilot

Experience JIL Sovereign's capabilities with a 90-day pilot

To demonstrate the effectiveness of our retail pharmacy fraud detection solution, JIL Sovereign offers a 90-day pilot program. During this period, payers can experience firsthand the benefits of our platform, including the identification of fraudulent activities and the generation of Court-Ready Evidence Bundles (CREB).

The pilot program allows payers to assess the impact of JIL Sovereign's solution on their fraud detection efforts and make an informed decision about long-term implementation.