TRICAST: Automates fraud, waste & abuse surveillance of pharmacy benefits

A powerful new version of a pharmacy risk, assessment, and reporting application detects FWA across the pharmacy benefits continuum

Milwaukee, WI – TRICAST, Inc. released today its newest version of a proprietary surveillance process that roots out fraud, waste and abuse (FWA) in pharmacy benefits programs, according to President/CEO Greg Rucinski. The management tool, which is software-driven, now boasts several functionality-enhancing modules.

“The TRICAST approach differs from how others look at pharmacy benefits data,” Rucinski said. Unlike many consulting firms, TRICAST performs a 100% electronic data audit of current PBM utilization, which is incorporated into a project analysis. This approach ensures accurate assessment and measurement of current pharmacy program performance.”

Rucinski continued, “TRICAST conducts four passes of the data for an FWA audit. This process deletes most false positives and dead ends while at the same time, creates views that consider appropriate, actionable criteria. Our reporting is always calibrated to provide actionable data that meets client response needs and capabilities. In addition, TRICAST’s reports are generated on the frequency basis that best suits a client’s particular needs.”

The first phase of an FWA audit is similar to that of a Pharmacy Benefit Management (PBM) audit except that the automated TRICAST process looks at the trending of data. Further distinguishing this approach is that TRICAST provides a view from multiple data sources, where outliers are noted via developed medians and other normative factors inherent in superior data analysis.

In phase two of the FWA process, TRICAST conducts a relational analysis between provider, patient and pharmacy data.

For phase three, TRICAST conducts triangulation that pulls out the top outliers in the data.

Finally, in the fourth phase, TRICAST validates against medical claims or implied diagnosis (if medical claims are unavailable).

Anomalies in pharmacy benefits data may take many forms. For example, a TRICAST audit may determine that potential fraud has occurred by detecting one or more common forms of “over-utilization” from the patient/physician/member perspective, including medication excess, dose duration or multiple providers and/or multiple pharmacies (i.e.: “doctor and pharmacy shopping”).

There are multiple challenges in tracking FWA that may not be fully captured in drug data analysis alone, and that are enhanced by inclusion of medical data. TRICAST’s approach provides dynamic tools that integrate various data sources to confirm suspected cases of FWA.

Examples of FWA monitoring provided by the TRICAST surveillance process include:

* Outlier utilization
* Drug-use abnormalities
* High-cost claim monitoring
* Inappropriate pharmacy network pricing
* Multiple members utilizing one card
* Abuse monitoring
* Manual claim submission integrity

New Capabilities Provide Compliance with CMS FWA Guidelines for Medicare Part D Plans TRICAST offers a complete suite of Medicare Part D audit services, including PDE, compliance, rebate, utilization management, clinical programs, and more. TRICAST’s FWA surveillance builds on CMS requirements for FWA monitoring and auditing and provides health plans and PBMs with the tools they need to demonstrate to CMS that they are fully compliant with CMS’s expectations for FWA oversight. By automating FWA oversight, TRICAST takes the burden off plan and PBM personnel and puts clear, actionable reports in the hands of the health plan and PBM staff that are most capable of acting on the report findings.

Likely users who will want to take advantage of the TRICAST FWA surveillance include:

* Health plans for both commercial and Medicare Part D needs
* Prescription Drug Program (PDP) sponsors
* Delegated entities such as Pharmacy Benefit Managers

“TRICAST solutions are all highly customized to our client’s particular needs,” Rucinski said. “Our audit tools provide immediate feedback on PBM and plan management accuracy. Clients can choose their level of involvement in our solutions through a continuum of options. TRICAST reporting experts work with clients to develop a solution that is custom-fit to their particular needs, staffing and budget. If desired, clients can utilize our web-based portals to manipulate data and generate reports, with full training and support from TRICAST staff.”

Rucinski added: “At the other end of the spectrum, clients may prefer a more formalized approach in which TRICAST generates reports and discusses them with designated staff. Our services provide measureable outcomes that benefit our clients and deliver a favorable impact on their compliance as well as their bottom line.”


Founded in 1997, TRICAST is a leading next-generation health information entity built specific to pharmacy benefits. We provide risk analysis and applications that support analysis and risk modeling for the healthcare industry. Our suite of software applications, expert audit and consulting services assist health plans in forecasting pharmacy costs. Visit to learn more.