PBM Match OPIS™

Core Concept: Combining retail pharmacy claims with medical claims to determine where claims have been paid inaccurately or have been paid in duplicate.

Pharmacy claims exist in a health plan in two distinct platforms or silos. Medical pharmacy claims are billed into the medical benefit of a health plan under a professional claim format such as an ANSI 837 or on paper as a CMS 1500 or UB 92. These claims are distinctively coded with HCPCs and are generally higher cost drug products than those associated with retail claims. Medical pharmacy claims are generated by physician offices, home infusion companies, out patient clinics and hospitals.

Retail pharmacy claims are processed, adjudicated and paid through a Prescription Benefit Manager (PBM) (i.e. Express Scripts, Argus, Caremark) with whom a health plan has contracted. These claims are generated by retail pharmacies. Health plans receive adjudicated retail pharmacy claims from the PBM. There is an expectation that what is submitted to the health plan from the PBM will be paid by the health plan due to the fact that the liability of adjudication rest on the PBM. Health plans rarely reprocess the claims and programs to detect fraud and abuse are left to the PBM in most cases.
Traditionally, the processing of retail claims is “siloed" from the rest of the medical claims and stands alone in its actuarial assessment and judiciary responsibilities and processes.
Because of this “siloing” of pharmacy data, two opportunities exist for the identification of incorrectly paid claims:

1. Traditionally, self-injectables drugs have been the responsibility of the physician to acquire and administer to the patient in the office setting. Due to the enormous influx of these high cost injectable drugs, retail pharmacies have been afforded the opportunity to dispense the drug to the patient with the expectation that the patient will take it to the physician office to have it administered. When the patient secures the drug from the retail pharmacy and takes it to the physician office to be administered, often times both entities (retail pharmacy and physician office) bill for the drug. This is due to the fact that the physician billing practice has difficulty separating the drug cost from the administration fee. The result is the health plan pays for the drug twice, once in the PBM and once from the physician’s office. This phenomenon of the patient receiving the drug from the pharmacy and taking it to the physician’s office for administration has been termed “brown-bagging.” It is an issue Medicare has identified and certainly affects the private payers as well.  

2. Once the PBM data is secured to review the “brown-bag” effect, it provides an opportunity to review the retail pharmacy data for fraud, waste and abuse. Claims from the PBM can go through the same process that has been identified for the medical pharmacy claims, where a PED is applied, outliers are identified, sent to validation then eventually recovered. In addition, by combining the data, trending and other opportunities can be identified. Very rarely does a health plan combine the PBM data with the medical data to get a comprehensive view of pharmaceutical care.

To summarize, by combining the PBM claims with the medical pharmacy claims we can identify:
1. Where a health plan may have paid for the drug twice, once from the PBM and once from the physician’s office
2. Duplicate billing by a single provider
3. Abberant provider reimbursement patterns