Analysis, data, and best practices on pharmaceutical loss prevention.
ANS Normative Resolution 659 marks a turning point in how Brazilian health operators will be supervised — and a leading signal for the broader Latin American market. This playbook translates what changes in operational terms, where pharmacy claims concentrate the most regulatory risk, and how to walk into the next audit cycle with an audit-ready program in 60 days.
Read moreDiabetes Mellitus is the single most exploitable diagnosis for waste, abuse, fraud, and leakage in pharmacy benefits. Vague diagnoses, clinically incoherent combinations, and repetitive prescription patterns create leakage that manual audit cannot catch at scale.
Read moreA comprehensive analysis of Latin American health insurance claims reveals that nearly half of pharmaceutical spend exhibits anomalous patterns representing $5.1M annually per 50,000 subscribers.
Read more96.8% of pharmaceutical spend goes to branded drugs, even though 71% have a generic available. The savings potential: $4.53 million annually per 50,000 subscribers.
Read moreFrom generic substitution to cloned prescriptions, these 6 patterns represent $5.1 million annually in detectable anomalies per 50,000 subscribers.
Read moreModern pharmacy fraud is organized, not individual. Claim-by-claim review fails because each isolated transaction looks legitimate. Cross-claim pattern detection is what reveals the networks.
Read moreThe largest healthcare payer in the world is using artificial intelligence to prevent fraud and has already saved $2 billion. Latin American insurers are still mostly relying on manual review.
Read moreTwo oncologists arrested in Cordoba after a 5-year investigation for false prescriptions. Prescriber anomaly detection can identify these patterns in weeks, not years.
Read moreThe traditional model of paying first and auditing later does not work. Recovery rates are low, investigation costs are high, and the fraud has already happened. Real-time authorization changes the equation.
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