PerformRx carefully monitors unusual patterns of prescription use by members, as well as prescribing patterns of physicians servicing our Medicaid and Medicare healthcare segments. If we identify patterns of fraud, waste, or abuse, we follow up with members and physicians, in conjunction with the health plan.
PerformRx reports suspected fraud, waste and abuse to the health plan, who then can follow up as appropriate. PerformRx's Fraud, Waste, and Abuse Identification and Prevention program is comprised of the following programs: PerformDUR, Pharmacy Network Auditing, and Member Lock-In.
Retrospective DUR
PerformDUR's retrospective DUR program provides systematic review of drug utilization and prescribing patterns to ensure member prescriptions are appropriate, medically necessary, and unlikely to result in adverse medical effects.
Pharmacy Network Auditing Program
PerformRx's network auditing program helps to prevent fraud and abuse. Pharmacies are selected for auditing based on high volume and/or high dollar utilization, according to the health plan's guidelines. Audit findings summaries and reports are available on a regular basis.
Member Lock-In Program
Upon customer request, PerformRx can provide fraud and abuse service in the form of member restrictions or a Lock-In Program. Under this program, identified members must obtain prescriptions from a specific physician or pharmacy to help ensure proper prescription compliance. PerformRx offers the health plan real-time capability to change a member's physician and/or pharmacy if necessary.
