Pro Pharma Pharmaceutical Consultants, Inc., a pharmaceutical consultant organization which focuses on pharmacy and medical data, announced today that it has finalized and validated a procedure for clients to design their own Custom MAC list. Pro Pharma’s processes allows clients to formulate a MAC list based on their design criteria, while Pro Pharma maintains and updates that list on a regular and timely basis.
“Clients can choose from design parameters based on which drugs and categories to include, manufacturer considerations, multiple bases of cost options (State, Federal, AAC, AWP, WAC, DP, U&C, Dispensing Fee),”, said Craig Stern, PharmD, MBA, President of Pro Pharma. “Pro Pharma can also assist with distribution (websites), maintenance, and pharmacy support.”
Health Plans and Medi-Medi Plans will find this service of particular value to meet State and Federal criteria for pricing. The customized fee schedule also allows Health Plans to address pharmacy complaints about MAC transperancy so that they can purchase drugs more effectively.
Medicaid is auditing generic drug payments and, in many cases, crediting capitation rates for claims paid above the Medicaid MAC rates. Medicaid is also auditing claims paid with an AWP above the statutory definition of WAC*1.2. In all cases Medicaid is auditing per claim.
Additionally, Medicare is auditing for valid NDC numbers (National Drug Code) and audits for valid physician identifiers (DEA or NPI) are imminent. Medicare is also auditing claims on a per-claim basis for payments consistent with the Medicare MAC, also known as the Federal Upper Limit (FUL). Health Plans are being scored based on compliance with Medicare benefits, claims payments, etc.
The bottom-line is that audits continue to expand and cover a wider scope. Medicaid and Medicare are less likely to negotiate audit findings than third party payers. As a result, oversight and monitoring of your Medicaid and Medicare benefits requires more timely interventions, and non-compliance must be corrected faster to avoid unnecessary penalties.
“Pro Pharma assists with Medicaid and Medicare benefit compliance, as close to real time as possible; namely, at the PBM invoice payment,” said Carol Stern, RN, BSN, MBA, Chief Executive Officer of Pro Pharma. “In this manner, you can proactively manage your benefit plans, as you don’t have to wait for reports from CMS, or Medicaid and Medicare audits to find out what is wrong.”
Pro Pharma’s customized fully transparent Client Specific MAC Lists can be administered and maintained on a monthly basis as follows to include, but not be limited to:
• Medicaid Compliance and/or CMS FUL Compliance;
• Adjustable Pricing Determinants (Lowest Cost, Average of Lowest 3 Costs, Average of all Generics, Median of all Generics);
• Multiple Price Sources, including: CMS, MediSpan, First Data Bank, Redbook;
• Customizable Therapeutic Categories;
• Flexible Generic Availability (Immediate availability, Predetermined time gap from end of patent, Minimum number of Generic Manufacturers, Decision allowance for generic, store brands, re-packagers, multisource, and/or branded generics);
• Modifiable Code Basis, including GCN, GPI, and NDC.
In addition, Pro Pharma’s Accounts Payable Reconciliation Audits (Invoice Screens™) include MAC compliance with State Medicaid MAC and the federal FUL. And Pro Pharma’s Part D Workbook tracks all elements of Part D in every invoice, at every month, every quarter, and every year in this Accounts Payable Reconciliation method to ensure that clients are aware of Part D non-compliance in claim adjudication.
Pro Pharma’s MAC Analyses™ allows your organization control oversight, corrective action planning, and implementation of changes for your Medicaid and Medicare books of business. At a cost of pennies PMPM, transparency is in your hands.
About PRO PHARMA
PRO PHARMA (propharmaconsultants.com) 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™, JCode Calculator™, Quality Management Program™, and Treatment Calendar™. The Company directly markets its products in the U.S. and collaborates with partners to reach international markets.
About Quality Management Program™ (QMP)
Pro Pharma’s Quality Management Program™ (QMP) is a multi-faceted approach that targets the pharmacy benefit cost and quality from multiple directions; namely, physician prescribing decisions, member demands, pharmacy oversight and patient education, HR rep education, and messaging to actives/retirees. The program is focused on providing patients and physicians specific tools designed to make more informed purchasing decisions that expand member co-pay dollars. The bottom line is: payers (self-insured, employers, Trusts, etc.) lower their pharmacy trend.
About Invoice Screening™
About 10% of drug spend is being paid from PBM Invoices, and should have been rejected by clients prior to payment. Pro Pharma’s Invoice Screening™ analyzes invoices against: formulary compliance, compliance with MAC pricing, eligibility, claims pricing, invalid claims, and excluded benefits, pre-payment as an Accounts Payable function. This ensures that clients only pay for valid claims, which saves time and dollars in the long run.
About JCode Calculator™
Pro Pharma has developed a Standardized Injectable Fee Schedule to assist with the management of claims payments. The advantage to this product is that it bases all Injectable reimbursement on AWP, WAC and ASP cost, and can be customized for drug category discounts or multiple discounts based on drug type or specialty. It includes at least one AWP for every HCPS Code and CPT code description; NDC, brand name, generic name, strength, package size, etc. This look-up reference tool provides non-pharmacist billing and claims personnel with the information and knowledge to process and reimburse claims in a timely, efficient and cost effective manner.
About Biotech Modeling™
Pro Pharma utilizes both the Medical and Pharmacy paid claims to analyze previous claims experience and to develop a model to project future trends. These issues center on the need for drug specific claims information, processing rules to ensure accurate quantities and maximum payment amounts, and rules for processing miscellaneous claims. The model can be updated with enhancements expeditiously given new Medical and Pharmacy claims experience.
Pro Pharma can identify immediate savings opportunities through re-modeling of claims processing procedures, and longer-term savings through technology assessment and utilization management. Additional research and analyses can be performed to determine the biotechnology drug driven costs in procedures, diagnostics, and provider time. It is expected that these adjunctive costs will represent an ever-larger portion of the ambulatory experience downstream
About Treatment Calendar™
Pro Pharma’s Treatment Calendar™ is a proprietary program comprised of Artificial Intelligence rule sets, which allow for quality and cost comparisons by peer-to peer, peer-to-best in class, peer to national norms, and peer to local norms.