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Analyze & Validate All Elements of Medical & Pharmacy Spend and Actions for Outlier Providers

We analyze pharmacy and medical encounter claims identifying outliers and testing for cost, diagnosis, dose, utilization and clinical reviews. Outcomes of these analyses are improvements in transactional issues and targeting outlier providers to prevent further problems. Our findings indicate that at least 42% - 44% of Specialty Medication claims require improvements.

    Analyses Include:
  • Comparison of pricing
  • Analysis of duplicate payments
  • Audits of specialty claims
  • Analysis of channel discounts

    Outcomes Include:
  • Medications paid at more favorable rates
  • Identification of claims paid for unapproved uses
  • Identification of clinical problems for targeting Improvement

Retrospective Audit at Work

Problem: A client wanted to submit rebates for specialty medical claims similar to what they were doing for the Specialty Pharmacy Claims. However, they were unable to identify which of the medical encounter claims for specialty medications were rebatable.

Methodology: We included rebate analysis in the Comprehensive Medical Specialty Analyses. A file of the rebatable encounter claims was made available for the client to submit to the manufacturers. The file included the NDC, manufacturer, effective and term dates along with all other applicable sterilized encounter claims data. The file also included a filter for potential 340b providers to remove from the file.

Alternatively, we also recommended that the client could include the rebatable specialty medical encounter claims with the pharmacy claims. Then the PBM could submit all the claims to the manufacturers for rebate reconciliation.

Outcome: The client was able to increase their rebate receipts by submitting both pharmacy and medical rebatable claims. The process was automated so that there was a minimal amount of manual data collection and processing.

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