Pro Pharma has developed this Standardized Injectable Fee Schedule to assist with management of claims payment of self injectables, vaccines, immunizations and cancer therapeutic agents.
Pro Pharma’s JCode Calculator™ Version-2 is a standardized injectable fee schedule which is updated on a quarterly basis, and accompanied by a customized Excel Workbook to meet Client requirements.
Pro Pharma provides secured access for Clients to the Pro Pharma secured website for quarterly updates and daily access and includes the following Key Features:
• Improved look up and History Functions;
• MMA Part B vs. Part D coverage;
• Differentiations between Brand & Generic Drugs;
• ICD-9 codes for Approved Diagnoses Identification;
• Expanded NDC lookups;
• Expected Package Quantity;
• Drug Alerts where appropriate.
“This update includes more than 70% price changes in our entire JCode Calculator™ database which consists of greater than 5000 entries. Additionally, this reflects all of the many AWP decreases mandated by the FDB/Medi-Span prior court decision”, said Craig Stern, PharmD, MBA, President of Pro Pharma. “This enhanced and expanded version allow Claims and Billing professionals to easily Identify all JCodes for any drug within seconds. Every entry on the JCode Calculator™ has a field that allows Billing and Claims Professionals to click and see all JCodes that pertain to that drug. This is only one of numerous filters that are user friendly, and customization is available per client request.”
This reference database also Includes, but is not limited to:
• HCPCS Code (including A, J, Q and S Codes);
• Current Procedural Code (CPC, formerly CPT) for drugs;
• Average Wholesale Price (AWP**) by package and pricing unit;
• National Drug Code number (NDC);
• Average Sales Price (ASP);
• Brand Name;
• Generic Name;
• Package Size;
• WAC (Wholesale Acquisition Cost).
** Other cost bases, besides AWP are also available.
The JCode Calculator is now available on a daily, weekly, monthly and quarterly basis and can be purchased on website.
Please visit Pro Pharma website for more complete information.
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™, 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.
Pro Pharma uses Clinical Protocols to analyze patient encounter data and diagnoses for required exams, tests, and medications. In this way, physician practices can schedule the applicable services for each patient and then review them for exceptions.
Treatment Calendar™ functions in the following manner as a:
• Quality tool for benchmarking;
• Tool to align provider and payer incentives by focusing on actionable patient specific quality improvements;
• Risk management tool to identify therapy that doesn't comply with national norms;
• Tool to graphically identify gaps in compliance.