Customized machine learning tools and technology tailored for the Canadian market help detect and prevent prescription fraud early

Toronto, Canada: 03/18/2021 — To help employers and health plans gain more control over fraud, waste, and abuse (FWA), MedImpact Canada Limited and SEB Administrative Services Inc. are launching an advanced analytics and reporting solution to combat FWA in Canada. The solution, powered by machine learning and artificial intelligence (AI), promotes payment integrity, compliance, and member safety.

Healthcare FWA runs the gamut from minor one-time overpayments to highly sophisticated criminal networks embezzling millions of dollars that result in higher healthcare costs, inappropriate clinical care, and tax administrative resources. In Canada alone, industry experts estimate 2% to 10% of every healthcare dollar is lost to fraud, costing $600 million to $3.4 billion annually.¹

“Traditional strategies to identify and mitigate FWA are no longer effective in today’s ever-evolving, high-cost healthcare landscape,” said Dan Parrish, Vice President, Underwriting & Pharmacy Analytics at MedImpact Healthcare Systems. “AI and machine learning analytics are imperative as a first step in identifying potential discrepant claims.”

In an effort to bring bold, time-tested solutions and innovative technology to Canadian employers and health plans, MedImpact Canada Limited formed a strategic business alliance with SEB Administrative Services (SEB Admin), a wholly owned division of Smart Employee Benefits Inc., to leverage the services of MedImpact Canada Limited’s affiliate MedImpact Healthcare Systems Inc. — the largest independent pharmacy benefit manager (PBM) in the U.S.

With more than 30 years of pharmacy benefit expertise, MedImpact Healthcare Systems customized the FWA pharmacy solution to meet the needs of Canadian employers and health plans. MedImpact Canada Limited is working with SEB to bring it to the Canadian market. Through AI and machine learning, the tailored solution captures and analyzes pharmacy dispensing patterns in Canada to help address Canada’s unique FWA challenges. The FWA solution is the first of multiple MedImpact solutions applicable to the Canadian marketplace.

“There is no independent pharmacy focused solution like this in Canada today,” said Mohamad El Chayah, COO of SEB and President/CEO of SEB Admin. “Our relationship with MedImpact Canada Limited allows us to unlock and extract exponential value to Canadian benefit plans by introducing proven AI solutions to combat FWA in the Canadian marketplace. This further emphasizes SEB’s efforts to provide Canadian public and private plan sponsors leading edge solutions that best optimize plan sponsor dollars to the benefit of plan members.”

FWA Analytics as a Service (AaaS) claim-level outlier scoring and rules flags monitor all activity to help ensure appropriate payments and clinical safety while summary reports track utilization and trends, providing plans:

• Comprehensive Oversight by continuously monitoring all claim activity to help ensure erroneous claims are not paid

• Loss Mitigation by streamlining early identification of potentially suspicious activity

• Investigative Efficiency by allowing plans to focus resources on high-risk activity with flags and scores generated by a data-driven, AI-powered outlier detection solution

• Insightful Reporting that helps plans stay ahead of emerging schemes by identifying high-risk trends and systemic issues through summary level reports

A global crisis

FWA is a worldwide healthcare crisis that costs an estimated $415 billion and accounts for 7.29% of total global healthcare spending every year, according to the World Health Organization.2 

“Internationally, fraud and overutilization of finite healthcare resources plague private and public payer systems — and Canada is no exception,” said Amar Mahmood, MD, PhD, General Manager, MedImpact International, an affiliate of MedImpact Canada Limited. “Prescriptions are the most prevalent intervention modality in healthcare. MedImpact employs the technologies to uncover hidden patterns across prescription data to effectively mitigate FWA and respond faster, should it occur.”

About Us
MedImpact Canada Limited

MedImpact Canada Limited is pleased to offer this FWA Analytics as a Service product to SEB’s clients through our strategic business relationship with SEB. Through this offering, Canadian entities will have the opportunity to benefit from PBM solutions targeting FWA, including holistic and coordinated data analytics, due to the relationship between MedImpact Canada Limited and its healthcare industry leading affiliates, such as MedImpact Healthcare Systems, Inc.

 

MedImpact Healthcare Systems, Inc.

MedImpact is the PBM that puts clients and consumers first. Always. For 30 years, we have had a single mission: To help make pharmacy benefits affordable, understandable, and honest. Today, our team and technology serve many large employers and plans and more than 55 million consumers in the U.S. and around the world. We are an independent company that answers to our clients, consumers, pharmacy partners, and employees — not Wall Street or a corporate parent. We are passionate about providing access to the lowest cost prescriptions. Learn more at medimpact.com or follow us on Twitter @MedImpact.

 

About SEB Administrative Services Inc. ("SEB Admin")

SEB Admin is a third-party administrator (“ TPA”) providing leading edge cloud based, fully bilingual, benefit processing solutions using SEB Admin’s proprietary technologies and custom solutions and services of Partners. SEB Admin’s “FlexPlus” ecosystem provides single sign-on connectivity for all group benefit stakeholders. Over $1 billion of premium is managed in the FlexPlus ecosystem. FlexPlus has over 20 modules supporting multiple revenue models, capturing and automating over 90% of all benefit processing activities for all benefit types. Each module can operate standalone or as an integrated solution. SEB Admin manages benefit plan environments for over 400,000 employees for more than 50 of Canada’s name brand companies and government entities and has reached agreements through its “Channel Partner” business model to white label its FlexPlus TPA solutions for over 150,000 additional plan members. FlexPlus cloud enabled solutions support all plan designs – traditional, flex, cafeteria, hour bank, dollar bank, marketplace – via co-sourced, fully outsourced or SaaS models.

 

For further information about SEB Administrative Service Inc., please visit:
https://www.seb-admin.com/.

About Smart Employee Benefits Inc.

SEB is a technology company providing Business Process Automation and Outsourcing software, solutions, and services to a national and global client base. SEB has a specialty growth focus in cloud enabled processing solutions for managing employer and government sponsored benefit plans on a BPO (Business Processing Outsourcing) business model, globally. SEB currently serves corporate and government clients across Canada and internationally. Over 90% of SEB’s revenues derive from government, insurance, and health care organizations. SEB’s technology infrastructure of over 650 multi-certified technical professionals, across Canada and globally, is a critical competitive advantage in supporting the implementation and management of processing solutions into client environments. SEB’s Managed Services & Solutions can be game changing for SEB clients, turning cost centers into profit centers.

 

For further information about Smart Employee Benefits Inc., please visit:
http://www.seb-inc.com/.

 

¹  Canadian Life and Health Insurance Association: https://www.canadianfraudnews.com/medical-insurance-fraud-widespread-as-employees-providers-rip-off-benefit-plans/

²  World Health Organization: https://www.who.int/bulletin/volumes/89/12/11-021211/en/

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