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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: One of our clients was concerned about comparing the medical versus the pharmacy specialty spend. Their primary concerns were the location of service and applicable costs, as well as the overall gross trend of their per-member-per-month (PMPM) trends. Separately, the clinical group within the organization wanted to know if their clinical cost control methods were effective on a total Plan as well as on a per provider basis.

Methodology: We analyzed every specialty medication claim from both medical and pharmacy data for this client each month. All findings were filtered by location of service, PMPM, provider specialty, disease/condition, provider, etc.

The analyses reported overall performance and compliance with a series of outliers – e.g., unmatched diagnoses, medications without applicable genomic testing, dosage within labeled min/max ranges, quantities within expected usage, pricing vs. lowest cost, pricing in compliance with contracts, rebates, value of wastage, etc. For the clinical group, all claims were analyzed for prior authorizations (PAs) for formulary exclusions, efficiency of prior authorizations and step therapy, adherence by drug and by category, etc.

Outcome: Financial savings for our client were identified on average of 42-44% of paid amounts. Clinical analyses identified beginning compliance of 50% and cost control methods, including PAs at 60% efficiency. After the implementation of the new process, the compliance increased above 80% and clinical cost control efficiency was above 70%.

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