ESI Pharmacy and Dental Audit and Fraud PreventionLeiza McGrath, ManagerProvider Auditth4 Annual Pharmacy & Dental Outcomes ConferenceDid you know…• Industry* estimate: 3 - 10% loss to fraud and abuse • 2004 - Canadian Health Care expenditures (drug and dental) approximately $31.1 Billion*$933 Million - $3.1 Billion!*Industry – National Heathcare Anti-fraud Association*Source Canadian Institute for Health InformationOptimizing the value of drug and dental benefitsKey MessagesManaging risks is the key to a successful Audit programESI Canada is:• Focused on becoming the leader in Dental and Health Provider Audit• The leader in Pharmacy Provider AuditOptimizing the value of drug and dental benefitsSo what is ESI Canada doing?Optimizing the value of drug and dental benefits999999ESI Canada’s Fraud PolicyFraud Tip Fraud & Abuse HotlinePrevention and Detection StrategyFraud & AbusePrevention and Detection PhilosophyE-mail reporting systemFraud & Abuse Strategy: Key ComponentsAudit Mission StatementOptimizing the value of drug and dental benefitsRisk Management• Identify significant existing and potential risks• Define, classifying and communicating risk • Provide a structured risk assessment on an ongoing basisOptimizing the value of drug and dental benefits999Technology• Significant investment in technologyAutomate manual functionsQuestionable claims identificationEnsure protection of private ...