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Innovative Analyses to Solve Medical Claims Reimbursement Headaches
Medical Specialty Claims Reimbursement Should Not be a Problem for Employers and Health Plans. The objective is to review Health Plan performance to make Specialty Rx more efficient, accurate and less costly.
By: Pro Pharma
A large public health plan in California identified issues in the payment of Specialty Pharmacy paid under the medical benefit. To detail their experience, Pro Pharma is co-presenting the key issues and solutions at the Annual Pharmacy Benefit Management Institute (PBMI) Drug Benefit Conference on March 7, 2018 in Palm Springs. Carol Stern, CEO of Pro Pharma, states, "All are welcome to attend, or contact me at Pro Pharma to obtain a copy of this meaningful and valuable PowerPoint Presentation."
Challenges tackled with a Game Plan to be addressed included the following:
- Different time with turn around requirements compared to UM
- Split Review/Decision - Administration portion should follow drug decision
- Claims System's Capability to conduct clinical /utilization edits are limited
- Claims System's Set Up is hard to navigate and often invisible
- Medical Documentation system CPT/drug code update
- Inappropriate decisions and payments
- Lack of real-time utilization trend reports
This presentation, entitled "Headaches No More – Improving Parity In Medical Specialty Reimbursement"
- The first step was to analyze the medical claims for common adjudication problems, e.g., matching to approved diagnoses, correct ICD10 coding, claim validity tests for dose/quantity/
- The second step was to inform the Information Technology (IT) department of the issues for corrective actions.
- The third step was to identify rebatable drugs for potential manufacturer discussions and contracting.
- The fourth step is to intervene with prescribers who are responsible for a high volume of adjudication issues.
Financial Returns on Investment (ROIs) with potential avoidance of overpayments of significant ollars every month are possible with the implementation with a proven Game Plan; including the following categories of Identification of paid vs contract amounts, claims exceeding utilization and claims exceeding maximum quantities.
About Pharmacy Benefit Management Institute:
The Pharmacy Benefit Management Institute (PBMI) is the preeminent thought leader in research and education in pharmacy management. PBMI helps healthcare and benefits professionals work with pharmacy benefit managers to design prescription drug benefit programs.
For 23 years PBMI has provided this truly educational venue to benefit decision makers and thought leaders interested in learning more about the drug cost management industry.
With courses ranging from introductory to advanced, PBMI online courses help deepen your understanding of the pharmacy benefit industry.
Hundreds of attendees will gather in Palm Springs, California for the Pharmacy Benefit Management Institute's (PBMI's) 23rdAnnual Drug Benefit Conference March 5-7. This event is the industry's only educational conference specializing in issues that impact drug cost management trends and draws a diverse range of key decision makers from employers, health plans, government entities, and academia who are interested in the latest events revolutionizing the drug cost management industry.
About Pro Pharma
Pro Pharma is a multi-service, woman owned, privately held consulting firm offering a vast portfolio of services to public and private entities including self-insured employers, Taft Hartley Trusts and unions, public employers, for-profit hospitals and integrated health networks, health care insurance companies, worker's compensation insurers, small-to-medium sized HMO's, and physician groups.
As a primary service to plan sponsors for achieving below trend results, PRO PHARMA provides an integrated program of administrative process improvements, clinical quality oversight, and provider/member education.
Pro Pharma's Consulting services are grounded in the use of data and the communication of that information to define benefit trends, drivers and other analytical indicators. Pro Pharma markets Biotech Modeling™, Invoice Screening™, Quality Management Program™, and Treatment Calendar™. The Company directly markets its products in the U.S. and collaborates with partners to reach international markets.
Pro Pharma Pharmaceutical Consultants, Inc.