Prescription Benefit Management Companies

Our core product is OPIS, whereby we receive paid medical claims and identify those claims that have a pharmaceutical component. Once these claims are identified they are subjected to a library of proprietary edits called PEDs (Pharmaceutical Edit Documentation). These edits are based on financial, clinical and procedural processes that may contribute to a claim being inaccurately paid.

Once a PED identifies a claim that is inaccurately paid it is sent to a validation team that further reviews the claim. If the claim is “validated” to be inaccurately paid, the system sends the claim to a recovery specialist who in turns contacts the provider and requests a refund.

OPIS and the additional products may be of value to your organization based on the following:

1. Applying our library of edits to your specialty pharmacy claims, prior to submission to member health plans, may result in maximizing billing and minimizing claims being rejected. OPIS not only reviews claims that are overpaid but also identifies claims that are significantly under-billed.
 

2. Private label the OPIS system to your member health plans to identify all of their overpaid medical pharmacy claims.

3. Once we are receiving all the paid medical claims of a health plan, we can provide data analysis on the current distribution systems of the member plans and provide a plan to move those prescriptions into your specialty pharmacy.

4. Provide general trend analysis reporting for pharmaceutical claims in the medical benefit.

5. Develop a system for creating rebates from the pharmaceuticals in the medical benefit spend.