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RxSentinel
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Pharmacy Fraud Detection

Intelligent fraud, waste & abuse detection for pharmacy billing

RxSentinel is an AI-powered platform that helps health insurance payers detect suspicious prescribing patterns, reduce investigator workload, and prevent improper payments — before they leave the door.

See How It Works
The Problem

Legacy fraud detection can't keep up with modern schemes.

Health payers lose billions each year to pharmacy billing fraud. Rule-based claim-edit systems miss novel patterns, generate high false positive rates, and leave Special Investigations Units buried in unactionable alerts.

Opioid overprescribing

Diversion-driven day-supply patterns that exceed specialty and geographic norms.

Brand-over-generic bias

Prescribing inflated by manufacturer payments or kickback arrangements.

Collusion networks

Coordinated provider-pharmacy-beneficiary rings invisible to single-claim analytics.

Alert fatigue

SIU teams drowning in false positives from rigid rule engines — real fraud slips through.

How It Works

A four-layer detection engine — each layer catches what the others miss.

RxSentinel combines modern machine learning with codified investigator expertise. The result is a ranked, explainable risk score your Special Investigations Unit can act on directly.

Layer 01
Supervised Learning
Gradient-boosted classifier trained on historical fraud outcomes — learns patterns that have already been confirmed.
Layer 02
Anomaly Detection
Unsupervised outlier detection for fraud patterns not present in labeled data — catches novel schemes.
Layer 03
Specialty-Aware Rules
Data-driven peer baselines that treat OB/GYNs, pain specialists, and oncologists differently — dramatically fewer false positives.
Layer 04
Explainability
Every flag carries plain-English reason codes and feature attributions. No black boxes; full audit trail.
Fraud Patterns Detected

Covering the full range of fraud archetypes from CMS and HHS-OIG.

1

Opioid overprescribing

Day-supply patterns exceeding specialty and geographic peer norms.

2

Brand-versus-generic bias

Prescribing inflated by manufacturer payment relationships.

3

Early refill / diversion

Refill cadence suggesting prescription churning or downstream diversion.

4

Out-of-specialty prescribing

Providers writing for drugs outside their clinical specialty — a recognized fraud ring indicator.

5

Phantom & duplicate billing

Repeated or impossible-day claim signatures surfaced at scale.

6

Collusion networks

Graph-based detection of coordinated provider-pharmacy-beneficiary rings.

Deployment

Built for investigator workflow. Deployed on your terms.

Every flagged prescriber includes reason codes, peer comparisons, and evidence drill-down. RxSentinel integrates with your existing SIU workflow and adapts to your payment pipeline.

Retrospective Batch Phase 1

Historical claims analysis to identify recovery opportunities. Start where the dollars have already been paid — quantify your leakage, then move upstream.

Real-Time Pre-Payment Phase 2

Claims scored before adjudication. High-risk claims routed to investigator review before payment leaves the door — prevent loss, don't just recover it.

Regulatory Defensibility

Designed for the audit, not just the spreadsheet.

Fraud analytics that flag prescribers without explainable evidence create legal and reputational risk. RxSentinel was built from the ground up to meet the standards expected under federal and state healthcare compliance frameworks.

Every flag carries evidence. Every decision carries a trail.

Risk scores are presented as statistical signals with supporting reason codes and feature-level explanations — aligned with the responsible fraud-analytics practices used by federal healthcare regulators themselves. Outputs support investigation; they do not substitute for it.

Reason Codes Plain-English explanation on every flag
Feature Attribution Per-prescriber importance breakdown
Audit Trail Complete lineage from data to disposition
Secure by Default Designed for HIPAA-aligned deployment

Ready to see RxSentinel in action?

Request a private demonstration. We'll walk you through the platform on public Medicare data so you can evaluate before committing to your environment.

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