Case Study: a leading U.S.-based biopharmaceutical company mitigates co-pay fraud with ZS Associates

Leading U.S.-based Biopharmaceutical Company flags $25M in co-pay fraud with ZS Associates

ZS Associates partnered with a leading U.S.-based biopharmaceutical company to address a significant challenge with co-pay card fraud in its specialty therapy program. The company suspected its program was a target for fraudulent claims, a persistent issue exacerbated by the high volume of transactions and sophisticated schemes that mixed fake prescriptions with real ones. Traditional, manual methods were insufficient to detect these complex activities.

The solution implemented by ZS was a proprietary machine learning-based system designed to analyze large datasets and flag anomalous transactions indicative of fraud. This multi-phase approach included an assessment, a proof of concept, and the scaling of an anomaly detection engine that continuously monitors for suspicious activity. As a result, ZS identified over 70 pharmacies linked to misuse. This led to over 20 pharmacies being blocked for their involvement in approximately $25 million of potential fraud, while another 50 were placed on a watchlist. The initiative also prompted legal action and revised eligibility criteria to prevent future fraud.

Leading U.S.-based Biopharmaceutical Company