Appropriate reimbursement for drugs covered by the medical benefit requires more data and structure than most medical claims or billing systems were originally intended to process. This applies even more so when the systems are proprietary. The tendency to solve this issue has been to apply headcount (ex- case workers & analysts), continually enhance existing systems, implement supporting procedures (ex- Prior Authorization), or outsource to a full-service vendor (ex- PBM, Medical Billing, or Payment Integrity partners). Any of these efforts, or combination of them, can result in suboptimal outcomes, limited visibility, and an unsustainable environment for controlling healthcare costs.
Available for download:
Automated Controls for Medical Drug Spend by RJ Health’s Chief Innovation Officer, George Herchenroether.
Appropriate reimbursement for drugs covered by the medical benefit requires more data and structure than most medical claims or billing systems were originally intended to process:
If you found this information about medically covered drugs helpful, you may also like to register for our upcoming webinar, Creating Pre-Payment Controls for Medically Covered Drug Costs through Automation.