Pro Pharma Pharmaceutical Consultants, Inc., a pharmaceutical consultant organization which focuses on data analytical expertise, announced today that the enhanced Invoice Screening™ is now available to assist with Accounts Payable reviews of Health Plan, PBM and TPA invoices performed weekly, biweekly, monthly or less frequently. It also includes True Out-of-Pocket Costs (TrOOP) validation and Medicare Part D.
There is another company in the North East corner of the country which announced their “New Approach: Reviewing the claims data with each invoice ensures cost savings and plan integrity”. This is EXACTLY what Pro Pharma’s Invoice Screening™ have been performing for clients for over twelve (12) years with excellent and validated returns on their investments.
Pro Pharma’s Invoice Screening™:
- Reviews 100% of the claims invoices for accuracy;
- Reviews PBM invoices which often contain significant overcharges;
- Review all PRE-PAYMENT to PBM;
- Allows Payers the ability to approve/disapprove payment for invoices before they make a payment;
- Reviews ALL prescription claims for cost accuracy, eligibility, and other key metrics;
- Turnaround time is 48-72 from receipt of complete data sets/invoices.
“Review of biweekly PBM Pharmacy Invoices for Pre-adjudication Claims can save you 10-15%", said Craig Stern, PharmD, MBA, President of Pro Pharma Pharmaceutical Consultants, Inc. “Savings for most clients are realized when Pharmacy Invoice Amounts are verified and Billing Details are screened against Formulary Compliance, Eligibility, Pricing/Mac Compliance, Invalid Claims and Excluded Benefits. Oversight and Management of Vendor Claims Adjudication “real time” puts control back into your pocket.”
Invoice Screening ™ eliminates payment errors, identifies problems previously unidentified or historically not addressed and puts money back in the organization’s pocket. Pro Pharma seeks to assist clients in minimizing their spend by identifying savings opportunities not commonly addressed by the PBMs. Pro Pharma will turn these reports back for management review/oversight/action within 72 hours after receiving complete data sets, to prevent payment rejections.
There are tools in place to provide plans with program information so that they can discuss cost savings options before State efficiency audits cause them to experience reduced capitation rates, with their Pharmacy Benefit Consultants and/or Pharmacy Benefit Managers (PBMs). This includes:
- Drug pricing consistent with the statutory definitions of AWP;
- Generic pricing consistent per-claim with Medicaid, Medi-Cal and Medicare rates;
- Claim validity checks before denials by the State or CMS.
To achieve savings these options must be available at point of invoice payment so that Finance Departments can ensure compliance with State and Federal payment guidelines. Essentially, the Accounts Payable Department, or function, must be able to audit pre-payment. Using current technology - Invoice Screening this is possible and is currently being performed in both public and private health plans.
Pro Pharma currently supplies Accounts Payable Departments with pre-payment pharmacy claims Invoice Screening™ that addresses all issues discussed above, and allows Health Plans to make appropriate cost saving decisions.
Please use this information to work internally to develop possible strategies to correct medical claim deficiencies before Medi-Cal reduces your capitation.
About Pro Pharma Pharmaceutical Consultants, Inc.
PRO PHARMA 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)
The QMP is a multi-faceted approach that attacks 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 directed to giving patients and physicians the tools to make better 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.
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 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.
About Biotech Modeling™
Pro Pharma (propharmaconsultants.com) 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.
Please visit Pro Pharma Pharmaceutical Consultants, Inc. website for more complete information.