Category Archives: Industry Insights

As drug spend increases, so does the use of genetic tests. How does this affect claims processing? Watch to learn more: VIEW THE FULL WEBINAR [TRANSCRIPT] So, the next question that we often hear from our clients is great, don’t need to worry about this on the pharmacy benefit, medical benefit, so what we did […]

INSIDE THIS ISSUE CMS News Drug Reimbursement Code Price Updates Drugs/Devices New Clinical and Billing Information Software Updates Prioritize your Code Level Pricing CODE UPDATES Large Price Changes: We identify and report on the codes with the most substantial pricing increases or decreases each month and detail the rationale for the change. Of the 35 […]

Of about clinical 1,400 studies, 34% were tied to some sort of genetic test. This will only increase over time. Watch to learn more: VIEW THE FULL WEBINAR   [TRANSCRIPT] Now, the other piece is, okay, great, so we have these 27 products, pretty small compared to the hundreds or thousands of products that we’re […]

In February there were two new drug approvals by the FDA we deemed specific to the specialty market. In addition, there were two supplemental drug approvals. The FDA had acted on assignment of new PDUFA dates for three new products for review. Finally, there was one complete response letter issued. Drugs included in this review […]

Today there are 27 drugs that have been approved by the FDA that have genetic companion diagnostics tied to them. Genetic-defined therapies are becoming more prevalent in many cases. Although not the case with every therapy, there is definitely a trend with drugs requiring genetic tests having a higher cost per treatment. Watch to learn […]

INSIDE THIS ISSUE CMS News: Home Infusion Therapy (HIT) Administration Codes are now Available Drug Reimbursement Code Price Updates: We review the reimbursement HCPCS/CPT® Codes in our system Drugs/Devices: New Clinical and Billing Information Software Updates: How to Locate a Drug Monograph CODE UPDATES Large Price Changes: We identify and report on the codes with […]

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 […]

In January there was one new drug approval by the FDA we deemed specific to the specialty market. In addition, there were three supplemental drug approvals. The FDA had acted on assignment of new PDUFA dates for three new products for review. Finally, there were two complete response letters issued and one manufacturer triggered withdrawal […]

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 […]

Enacted in 1992, the Prescription Drug User Fee Act (PDUFA) was created to authorize the Food and Drug Administration (FDA) to collect fees from companies that produce certain human drug and biological products. These fees serve as a secondary source of funding for the FDA and serve to expedite the review process.  The FDA establishes […]