Customized machine learning tools and technology tailored for the Canadian market help detect and prevent prescription fraud early
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March 18, 2021 08:00 AM Eastern Daylight Time
TORONTO--( BUSINESS WIRE )--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 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: http://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/
Contacts

MedImpact and SEB Bring Artificial Intelligence FWA Solution to Canada

September 24, 2020 08:00 AM Eastern Daylight Time
SAN DIEGO--( BUSINESS WIRE )-- MedImpact today announced a new solution that integrates prescription discount card savings with traditional plan prescription benefits. This solution will provide health plans with a more complete view of member utilization and adherence, while reducing the cost of prescriptions for members. “Tracking adherence is essential for health plans to improve health outcomes, CMS Star Ratings, and competitiveness,” said Dale Brown, President of MedImpact Healthcare Systems . “This solution will give health plans the ability to integrate funded and unfunded claims to lower costs, improve health data and outcomes, and simplify the entire process for consumers.”
Over the past few years, prescription savings programs have skyrocketed in popularity. In particular, as copays and deductibles rise, the price of medications with a discount program may be less than the insurance out-of-pocket cost for the same drug. As a result, consumers are bypassing their prescription insurance and purchasing medications -- including drugs that are on their plan’s formulary -- with cash. According to a recent online poll conducted on behalf of MedImpact, involving 500 people with insurance coverage, 25% of respondents said they have used a prescription savings program within the past year; 8% said they use it every time they go to the pharmacy. For insurers, this is resulting in significant gaps in data on member health, utilization, and adherence. MedImpact’s integrated solution will offer health plans the opportunity to adapt to this fast-moving trend in consumer behavior and capture critical information that they cannot access currently. In addition to capturing claims data, funded plans will also be able to apply cash claims to the member’s deductible, consistent with applicable law and the terms of the individual plan. This has the potential to provide members with lower annual drug costs and a better pharmacy benefit experience. “Managing overall prescription costs shouldn’t be so complicated,” said Brown. “Members with funded benefits will be able to use their benefits card with the confidence knowing that they will receive the lowest out-of-pocket cost each time they go to the pharmacy.”
MedImpact’s integrated solution will be ready for implementation in 2021. About MedImpact
MedImpact is the PBM that puts clients and consumers first. For 30 years, it has had a single mission: To make pharmacy benefits affordable, understandable, and transparent. Today, MedImpact’s team and technology serve many large employers and plans, and more than 55 million consumers in the US and around the world. Learn more at medimpact.com or follow us on Twitter @MedImpact .

MedImpact Integrated Solution Helps Plans Reduce Member Drug Costs and Obtain More Complete Data on Utilization, Adherence

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SD 500: Frederick Howe

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SilverStream Capital

MedImpact HealthCare Systems

Sculpture Hospitality

Canaan

TPG Capital

IMS Health

MedInitiatives

inVentiv Health

Express Scripts

Anthem

Pharma Supply Chain

Unattributed VC

Unattributed VC - II

Unattributed VC - III

MedImpact Healthcare Systems is a full-service Pharmacy Benefit Manager (PBM) that derives revenue by managing the drug benefit, not from dispensing drugs. The company uses information technology and human capital to improve the practice of managed care pharmacy. MedImpact partners with the nation's finest health plans, hospitals and employers to provide pharmacy benefit management services to more than 35 million members.

Name	Matthew Simas
Firm	SilverStream Capital
Work History
Other Seats	MedImpact HealthCare Systems

Name	Work History	Title	Status
Dale Brown		President	Former
David Wheeler	SilverStream Capital, and Sculpture Hospitality	Chief Financial Officer	Former
Matthew Simas	Canaan, TPG Capital, SilverStream Capital, IMS Health, and MedInitiatives	Executive Vice President	Former
Jason Twombly	inVentiv Health, Express Scripts, and Anthem	Senior Vice President	Former

Name	Dale Brown	David Wheeler	Matthew Simas	Jason Twombly
Work History		SilverStream Capital, and Sculpture Hospitality	Canaan, TPG Capital, SilverStream Capital, IMS Health, and MedInitiatives	inVentiv Health, Express Scripts, and Anthem
Title	President	Chief Financial Officer	Executive Vice President	Senior Vice President
Status	Former	Former	Former	Former

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