Employers and Unions
Medicare RDS Cost Reports
Core Concept: Produce reports of paid retiree retail pharmacy claims in order for the employer/union to receive a subsidy from CMS for retaining their retirees on their drug program.
Provide Retiree Drug Subsidy Reporting to employers/unions seeking the CMS 28% tax free subsidy from Medicare Federal Trust Fund. There are over 50,000 employers that have pursued RDS for 2006.
In many instances an Employer may have their retiree prescription benefit split between multiple PBMs or health plans which may require an aggregation of eligibility and cost data files. If these retirees are under the same application and unique benefit option it may be necessary to combine the data for the submission of cost reports to CMS to acquire the subsidy. The cost data and subsequent RDS payments are subject to the False Claims Act and therefore employers need to be sure to follow the RDS Payment Guidelines as accurately as possible. SPN can take claims data and eligibilty information from a variety of sources, in any format, and accurately produce the CMS cost reprorts.
Medical Pharmacy OPIS™
Core Concept: Identifying, validating and recovering paid medical claims that represent pharmaceutical care.
This product is the core or flagship product of SPN. Paid medical claims are entered into SPN’s OPIS™ database. These claims then are subjected to a library of edits called PEDS (pharmacy edit documentation), which identify medical, retail or specialty pharmacy claims that have been inaccurately paid due to financial, clinical or procedural errors. These identified claims are then organized as inventory and presented to a user on the OPIS system referred to as a validator. The validator reviews the claims and validates the PED’s accuracy. Once the accuracy of the overpayment is confirmed the claim is then presented to a recovery specialist, who in turn utilizes the OPIS application to contact the provider and request overpayment. The entire cycle of identification, validation and recovery is done through the OPIS application.
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
OPIS Pre-Pay/Pre-Pricing™
Core Concept: Applying edits or pricing methodologies before the claims are paid, thus eliminating recovery. SPN can take in a NDC, price the product based on that NDC and pricing methodology, and then convert the NDC to the appropriate HCPC code.
Pre-Pay: Post-adjudicated claims that are scheduled to be paid are run through the OPIS system and validated, at which point the client is notified of any overpayment, can suspend payment on all overpaid claims and then pay the correct amounts. This service offering is attractive based on the fact that there is no associated recovery process.
Pre-Pricing: SPN can provide pre-pricing services to payer clients prior to claim adjudication. Pre-Pricing differs from Pre-Pay in that the claim is priced and subjected to various edits prior to the payer internally adjudicating the claim.
Retro Term OPIS™
Core Concept: Identifying retail pharmacy claims that have been paid for ineligible members of a health plan.
Identify and recover retail pharmacy claims where the health plan had inadvertently paid claims for patients which no longer have coverage under the health plan.
Health plans routinely receive eligibility information from employers that is inaccurate. This leads to health plans paying for retail pharmacy claims for employees that either no longer have coverage or where the employer group has switched health plans and has failed to notify the health plan in a timely manner.
The OPIS system has the ability to load retail and eligibility information, identify patients whose coverage has terminated and facilitate recovery from the patient or assist the employer in re-submitting patient claims to the correct health plan.
Retail Pharmacy OPIS™
Core Concept: Data mining for inaccurately paid retail pharmacy claims that have been adjudicated by a PBM.
Identify, validate and recover retail pharmacy claims that have inaccurately processed and paid by a health plan’s PBM. Retail claims are subject to the same type of edits imposed on medical pharmacy claims based on financial, procedural and clinical errors.
Data Analysis Services
Core Concept: Produce reports based on the patient, product, plan, prescriber and provider in order to more effectively manage the medical and retail pharmacy spend.