Drugs covered under medical benefit plans and their costs are difficult to manage.
These challenges are due to:
• Limited clinical visibility and control
• Unaccommodating medical claims and claim systems
• Complex billing and reimbursement requirements related to coding and pricing
As a result, medically covered drug claim errors are almost the norm. In a study of RJ Health 2018 client claim data, the application of RJ Health Medical Claim Edits resulted in the real-time provision of corrected values for over 50% of submitted claim lines.
In fact, automated medical drug edits can be applied prior to claim submission or adjudication to assure:
• Accurate unit cost management for all drugs covered under the medical benefit
• Appropriate pricing methodologies and fee schedules
• NDC to HCPCS/CPT alignment and billable unit conversions
• Dose limit accuracy for both FDA and Compendial indications
• The utilization of NDC pricing for drugs aligned with NOC Codes
• Accuracy in these areas will reduce appeals, delayed payments, and improper reimbursement, particularly for claims with NDC mandates for both Government & Commercial memberships.
We invite you to send us some sample claims data to help you size the ROI opportunity for your organization.
Continue reading in part 2:
For more on RJ Health’s Medical Drug Edits and API services, view our on-demand webinar:
A discussion on medical benefit drug management challenges and opportunities for pre-payment automation within your organization.
To view the transcript and deck, CLICK HERE.