Looking Back to Predict the Future
Pro Pharma's philosophy is that you need to have a benchmark of utilization and performance by conducting a Retrospective Audit, in order to measure and set the bar for improvement.
By: Pro Pharma
Carol Stern, CEO notes, "We perform retrospective pharmacy claims audits to ensure compliance with PBM contracts". She goes on to state that "Pro Pharma is sensitive to conflicts over audits and makes every effort to identify those areas requiring validation and to work with all parties to ensure contract compliance."
Fundamental Areas for a Comprehensive Audit Are:
• Formulary Compliance
• Pricing/MAC Compliance
• Invalid Claims
• Excluded Benefits
Pro Pharma's digital approach to Pharmacy Claims Audits is performed on 100% of the organization's pharmacy claims (medical encounter data can be incorporated for the same time period); identifies the outlier physicians and pharmacies; and provides supporting information to expedite the process
Pro Pharma's comprehensive approach to audits and analyses can be summarized as follows:
• Analyses that identify opportunities with rapid cost savings corrections
• Invoice Screens™ (concurrent audit/analyses)
• Management through Invoice Screens™ to identify opportunities to improve downstream cost control
• Analyses of MAC Pricing fees to improve savings to purchasers
• Improves Benefit Rules to capture more brand/generic savings for Plans and Member copays
• Identifies High Risk Providers and work with them through peer-to-peer comparative measurements to decrease the variability in their prescribing
• Identifies potential for fraud, waste and abuse, and uses data to change behaviors of target providers
To learn more about Pro Pharma's Retrospective Audit visit: http://propharmaconsultants.com/
Pro Pharma offers Retrospective Audit at Work as a real-life scenario to answer those clients wanting to review a Case Study approach:
Problem: Clients ask if Audit help them to understand why costs so high? This client requested an expedited Retrospective Audit to determine the drivers of cost and the options available for change.
Methodology: Pro Pharma performed a Retrospective Audit including tests for eligibility, benefit compliance, brand and generic pricing, specialty pricing/utilization, benchmarking to national and local standards, and transparency in bases of cost. The Audit was expedited utilizing a 100% electronic/digital approach to produce valid and efficient results with a quick turn-around-
• Potential problems with formulary claims that were coded as Brand when the Plan Expected Generics
• Problems with transparency such that AWP was inflated from national reference databases
• Specialty approved for total Rx without tests for FDA approvals, quantity, dosage and companion diagnostic tests
• Pricing above benchmarks, discount generic programs, Medicare/Medicaid when applicable, and patients paying more than cost of drug
Outcome: The client used the findings to redirect coding options to include only Generic formulary options for multisource (especially timed-release products), OTC, store brands and private labels. They worked with the PBM to correct inflated AWP issues, and variances from Medicare and Medicaid.
The client moved specialty to Prior Authorization (PA) and improved criteria. They expanded their benefit to include payments for discount Generic programs.
The result was normative pricing that was measurable and validated, low single digit point-of-sale trends, and a solution for analyzing future spend.
The client now possessed the appropriate tools so that they were in control, as they were equipped with a plan, an understanding of the drivers of cost and savings, a solution for matching actual spend to expectations, and improved satisfaction.
According to Craig Stern, President, "The end result of using measurement to target change can only be effective when it is combined with a management approach to effect the change that is desired. Data analytics is necessary, and crucial, but it is not sufficient. When all the options are on the table, they can be prioritized. Prioritization leads to prescriptions for change. Prescriptions for change require action. While no situation or purchaser is the same, the need for measurement, analysis and actionable results is a constant."
Call us at (888)701-5438 ext. 725 or email at email@example.com to schedule a Live Demo so that we can ascertain your specific needs and tailor and custom-made approach to garner positive results.
About PRO PHARMA
Pro Pharma is a Healthcare Data Analytics and Consulting Firm. We are woman owned and privately held; offering a vast portfolio of services to public and private entities including self-insured employers, 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.
For more information about PRO PHARMA, please visit http://www.propharmaconsultants.com.
Pro Pharma Pharmaceutical Consultants, Inc.