Pharmacy fraud, waste and abuse (FWA) is estimated to cost the U.S. health care system $3.5 billion annually.2 In pharmacy settings, waste and abuse can include unintentional issues such as duplicate therapy or unnecessary refills, but in more limited cases, fraud can be intentional actions like over-billing, billing for brand drugs while dispensing generics or prescription forgery.3
When AI and pharmacy team members work together, patients are safer
Optum Rx combines AI-enabled analytics with human review to spot potential FWA in real time and help pharmacies and patients:
A patient was at risk of receiving two different doses of the same medication. In real time, Optum Rx’s AI-enabled analytics flagged the double dose and alerted a human auditor who quickly contacted the pharmacy to verify the prescription. The pharmacist was able to correct the prescription before the medication was dispensed, avoiding potential harm to the patient and preventing an unnecessary copay.
In another case, a pharmacist unintentionally ordered more than 30 cases of medication that was not needed. AI flagged the unusual quantity and days’ supply to a human auditor, prompting the auditor to call the pharmacy. That call led to the pharmacist canceling the order, avoiding extra inventory and unnecessary spend, protecting both the pharmacy and the client.
These stories show how Optum Rx uses AI not to replace pharmacists, but to support them and help catch issues early in a fast-paced environment.
Context: Traditionally, auditors have reviewed large volumes of claims manually to find irregularities. Today, Optum Rx’s AI-enabled analytics spot potential FWA in real time and by using retrospective audits. By analyzing claims data during and after billing, AI flags unusual patterns sooner and highlights characteristics common to fraudulent cases. This approach helps auditors focus on the highest risk activity to protect clients and increase patient safety.
In addition to real-time audits, Optum Rx also uses AI and machine learning models to support retrospective audits (fraud investigations, desk and onsite audits).
By the numbers
Results for clients, pharmacists and patients:
The AI/ML model drove a 35% reduction in low‑value retrospective audits — those unlikely to result in FWA findings — minimizing unnecessary pharmacy disruption and enabling greater focus on patient care.
Audits recover an average of $2M for clients using advanced pharmacy audit services.
Medication errors are prevented, reducing unnecessary costs and protecting patients from potentially unsafe treatments*.
"[Optum Rx] executes a compliant audit program fair to the network to catch the FWA but do not overwhelm the good actors.”
Optum Rx Client
Built for better health
Powered by more than 10,000 AI expert engineers and over 1,000 enterprise solutions in use across UnitedHealth Group, Optum Rx continues innovating to solve today’s challenges and scaling to meet tomorrow’s demands – supporting nearly 61 million members with personalized care, helping 1 million providers make faster, more informed decisions, and empowering more than 5,000 clients with real-time benefit management – reinforcing its position as an industry leader in responsible AI and a simplified healthcare experience.
The bottom line
Ethics and human judgement remain critical to Optum Rx’s approach. A company-wide responsible AI program, that includes governance, reviews AI use cases to ensure they are used ethically and deployed safety.
1 Total number of retail prescriptions filled annually in the U.S. 2013-2025 | Statista
2 Timofeyev, Y., Hayes, S. A., & Jakovljevic, M. B, ‘Predictors of loss due to pharmaceutical fraud: evidence from the U.S. Cost effectiveness and resource allocation.’ National Library of Medicine, February 2022.
3 Optum Rx Pharmacy Provider Manual
*2024 Results based on internal analysis conducted in 2025
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