Methods and systems for drug purchase validation

Abstract

Methods and systems for drug purchase validation are described. In an example embodiment, drug sale data is accessed from a prescription drug wholesaler regarding prescription drugs sold to the pharmacy by the prescription drug wholesaler during a period of time. A number of units of a prescription drug sold to the pharmacy are determined based on the drug sale data during the period of time. Pharmacy claims data over the period of time is accessed, where the pharmacy claims data reflects a plurality of adjudicated claims, and the plurality of adjudicated claims are a plurality of claims that were submitted for adjudication by the pharmacy during the period of time. A number of units of a prescription drug associated with the plurality of claims submitted during the period of time by the pharmacy for adjudication are determined based on the pharmacy claims data. The number of units of the prescription drug associated with the plurality of adjudicated claims that were submitted for adjudication by the pharmacy is compared with the number of units of the prescription drug sold to the pharmacy. A determination is then made as to whether a discrepancy exists based on the results of the comparison. Additional methods and systems are disclosed.

1 . A method comprising:
 determining, by a processor, a sold amount of a prescription drug sold by a prescription drug wholesaler to a pharmacy during a retrospective time period based on prescription drug wholesaler sale data of the prescription drug wholesaler;   determining, by the processor, an adjudicated claims amount of the prescription drug associated with a plurality of adjudicated claims for a corresponding time period to the retrospective time period, the plurality of adjudicated claims being a plurality of claims of the corresponding time period that were submitted on behalf of the pharmacy and adjudicated and dispensing approved by a benefit manager, the dispensing approved reflecting approval by the benefit manager of the plurality of claims for dispensing by the pharmacy;   comparing, by the processor, the adjudicated claims amount of the prescription drug associated with the plurality of adjudicated claims with the sold amount of the prescription drug sold to the pharmacy; and   determining, by the processor, that a discrepancy exists based on a result of the comparison reflecting that the pharmacy has filled prescriptions for more prescription drugs than the pharmacy has purchased.   
     
     
         2 . The method of  claim 1 , where determining that the discrepancy exists comprises:
 determining that the discrepancy exists where the adjudicated claims amount that was submitted for adjudication by the pharmacy is greater than the sold amount of the prescription drug sold to the pharmacy by a predetermined level.   
     
     
         3 . The method of  claim 1 , further comprising:
 generating a pharmacy explanation request to request an explanation of the discrepancy from the pharmacy; and   transmitting the pharmacy explanation request to a pharmacy device, the pharmacy device being associated with the pharmacy.   
     
     
         4 . The method of  claim 1 , further comprising:
 determining an excess amount of the prescription drug associated with the plurality of adjudicated claims that were submitted for adjudication by the pharmacy greater than the sold amount of the prescription drug sold to the pharmacy;   generating a pharmacy reimbursement request for reimbursement of the excess amount of the prescription drug.   
     
     
         5 . The method of  claim 1 , further comprising:
 identifying a high risk drug;   accessing claims data submitted during a period of time for the high risk drug by the pharmacy;   determining a number of high risk drug adjudicated claims relating to the high risk drug during the period of time based on the claims data; and   selecting the pharmacy for verification where the number of claims submitted by the pharmacy relating to the high risk drug is greater than a verification criterion.   
     
     
         6 . The method of  claim 5 , where the verification criterion is a determined amount of adjudicated claims associated with the high risk drug. 
     
     
         7 . The method of  claim 1 , further comprising:
 harmonizing the sold amount of the prescription drug sold to the pharmacy with the adjudicated claims amount of the prescription drug submitted by the pharmacy for adjudication such that a number of doses, dosage, and capsule type for each are of a comparable type.   
     
     
         8 . The method of  claim 1 , further comprising:
 identifying the prescription drug wholesaler that sell the prescription drug to the pharmacy; and   transmitting a drug sale data request to a prescription drug wholesaler device associated with the prescription drug wholesaler.   
     
     
         9 . The method of  claim 1 , further comprising:
 generating a physician verification request for requesting verification of a claim from a physician; and   transmitting the physician verification request to a physician device, the physician device being associated with a physician.   
     
     
         10 . The method of  claim 1 , further comprising:
 generating a patient verification request for requesting verification of a claim from a patient; and   transmitting the patient verification request to a patient device, the patient device being associated with a patient.   
     
     
         11 . The method of  claim 1 , where drug sale data includes invoice data relating to sales of drugs from the prescription drug wholesaler to the pharmacy. 
     
     
         12 . The method of  claim 1 , wherein adjudication by the benefit manager includes eligibility verification, co-pay determination, and drug utilization review. 
     
     
         13 . The method of  claim 1 , wherein the prescription drug wholesaler purchased the prescription drug from a drug manufacturer of the prescription drug and sold the prescription drug to the pharmacy. 
     
     
         14 . The method of  claim 1 , wherein the prescription drug wholesaler sale data includes data received from a drug wholesaler in response to an inquiry regarding specific quantities of the prescription drug sold to the pharmacy. 
     
     
         15 . A non-transitory machine-readable medium comprising instructions, which when executed by one or more processors, cause the one or more processors to perform the following operations:
 determine a sold amount of a prescription drug sold by a prescription drug wholesaler to a pharmacy during a retrospective time period based on prescription drug wholesaler sale data of the prescription drug wholesaler;   determine an adjudicated claims amount of the prescription drug associated with a plurality of adjudicated claims for a corresponding time period to the retrospective time period, the plurality of adjudicated claims being a plurality of claims of the corresponding time period that were submitted on behalf of the pharmacy and adjudicated and dispensing approved by a benefit manager, the dispensing approved reflecting approval by the benefit manager of the plurality of claims for dispensing by the pharmacy;   compare the adjudicated claims amount of the prescription drug associated with the plurality of adjudicated claims with the sold amount of the prescription drug sold to the pharmacy; and   determine that a discrepancy exists based on a result of the comparison reflecting that the pharmacy has filled prescriptions for more prescription drugs than the pharmacy has purchased.   
     
     
         15 . A system comprising:
 a processor and a memory;   a subsystem deployed in the memory and executed by the processor to determine a sold amount of a prescription drug sold by a prescription drug wholesaler to a pharmacy during a retrospective time period based on prescription drug wholesaler sale data of the prescription drug wholesaler, determine an adjudicated claims amount of the prescription drug associated with a plurality of adjudicated claims for a corresponding time period to the retrospective time period, the plurality of adjudicated claims being a plurality of claims of the corresponding time period that were submitted on behalf of the pharmacy and adjudicated and dispensing approved by a benefit manager, the dispensing approved reflecting approval by the benefit manager of the plurality of claims for dispensing by the pharmacy, compare the adjudicated claims amount of the prescription drug associated with the plurality of adjudicated claims with the sold amount of the prescription drug sold to the pharmacy, and determine that a discrepancy exists based on a result of the comparison reflecting that the pharmacy has filled prescriptions for more prescription drugs than the pharmacy has purchased.