Author Archives: Wendy Sullivan

Below is the transcript and demo from our on-demand MicroWebinar:  Road Testing the RJ Health Medical Drug Edits and API Platform RJ Health’s MDEs intake customer claim data and apply our best in class medically covered drug data and algorithms in order to improve reimbursement timeliness, drug coding, and payment accuracy, drug formulary adherence, and […]

In Medical Drug Edit Blog Posts #1 & #2, we learned how Medical Drug Edits can enhance Medical Drug claim submission and reimbursement accuracy.  However, the utilization of an API (Application Programming Interface) to deliver Medical Drug Edits can further improve the Medical Drug pre-claim review process. Specifically, the use of an API can: Speed […]

Our latest white paper demonstrates the value and versatility of an automated medical drug claim edits solution. RJ Health’s system implements a rules-driven platform to reduce overall medical drug claims errors and improve overall efficiency. Appropriate reimbursement for drugs covered by the medical benefit increasingly requires more data and structure. Many of the billing systems […]

In Medical Drug Edit Blog Post #1, we saw that pre-payment edits of Medical Drug claims can be utilized to improve claim submission and reimbursement accuracy.  Payors and providers license RJ Health’s Medical Drug Edits and access them via our API platform. This is because effective pre-payment review of medical drug claims requires: •  The […]

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 […]

Hello. I am Wendy Sullivan, Director of Drug Informatics for RJ Health. I’d like to welcome you to today’s webinar-Creating Pre-Payment Controls for Medically Covered Drug Costs through Automation. Before we get started, I’d like to thank you for attending and to thank my colleagues who helped make this webinar possible. In terms of my […]

In an effort to contain growing healthcare costs, Congress enacted the Omnibus Budget Reconciliation Act of 1990 (OBRA’90) and created the Medicaid Drug Rebate Program. Pharmaceutical manufacturers’ participation in the program became a prerequisite for Medicaid coverage of outpatient prescription drugs.Since then, states have been required to collect associated drug rebates to receive federal funding […]