prescription benefit market is enormous with over 3.8 billion prescriptions worth $ 291 billion in prescription drug sales in 2008 alone. The largest pharmacy benefit plans in the US are run by the government (Federal, State and local), followed by health insurance companies, self-insured companies and unions.
two (2) weeks, PBMs send out accounts for almost $ 11 billion of prescription claims. This pharmacy bills are usually paid without review in forty-eight (48) hour time frame required by most PBM contracts. Benefit Administrators will to fulfill its fiduciary responsibilities and ensure accurate billing, but always thought it impossible to review the tens or even hundreds of thousands of claims each account before payment … until now.
Recent articles in the New York Times and Wall Street Journal noted the current practices PBM companies. With pressure building on businesses and the legislative and executive branches of government, companies benefit donors, it is a foregone conclusion that the market will require increased transparency for the PBM business. While many human resources and pharmacy benefits consultants are trying to co-op PBMs negotiate pharmacy benefit savings through collective bargaining and retrospective PBM audits, one company has emerged that has made it a mission to ensure that the primary PBMs live up to the terms of their contracts. Contract negotiations are meaningful only when you have faith that the agreement is honored.
The recent developments in the Health Information Technology Company’s Pharmacy Claims Analytics (“PCA”). This new technology provides pharmaceutical sector pension sponsors with technology tools to implement PBM contracts confirm the accuracy of the invoice costs, and ensure PBM responsibility. These providers are delivering solutions for PBM responsibility by making payers of prescription benefits for reviewing the accuracy of 100% of the claims PBM their accounts before paying account. In fact, this provides a real-time PBM audit by providing advance payment Audit account for errors. PCA technology companies make payers Pharmacy benefits to prevent waste and abuse, take control of rising Pharmacy Benefit Manager (PBM) costs, and meet regulatory compliance requirements of Sarbanes Oxley (SOX), HIPAA, Medicare Part D and FTC Red-Flag.
Pharmacy Claims Analytics offerings should at a minimum provide
1) Analysis of 100% PBM invoice pharmacy claims
2) Self-service account load and automatic reporting output
3) Web based Application Service Provider (“ASP”) model
4) Potential Demand Analysis (completed before payment of the PBM account)
While many companies offer manual demand review of qualified consultants and industry experts, only Pharmacy Claims Analytics technology companies put the payer in control by automating this legacy manual processes.
Benefit Managers are committed to fulfill their fiduciary responsibility by ensuring the best benefits for their plan members. To do this, companies interact Benefit Advisory Groups and work to negotiate the best possible agreements pharmacy benefit. It is not enough to negotiate a good contract PBM. Benefit Managers need tools to monitor, measure and enforce PBM contract.
PCA technology are purpose built for pharmacy benefits management and consulting firms. PCA technology support products payables process, actuarial analysis and regulatory compliance. Companies often have a permanent and positive relationship with their PBMs. Inspection 100% of claims PBM accounts is not to express distrust or disapproval. It is the fiduciary responsibility of the payer, it protects plan members, and it is a regulatory compliance requirement. If you have not checked Pharmacy Claim Analytics technology solution you should.
Trust but Verify.