Category Archives: Whitepaper

Each year there are dozens of new drugs (56 in 2018) and new CMS HCPCS assignments (38 in January 2018), as well as hundreds of new indications approved. This is in addition to the ongoing updates in coding assignments, pricing, generic entries and more. Consider that the average cost for a medically covered drug is […]

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 […]

Medically covered drug pricing is highly sensitive, and changes occur frequently. The more variability in a system, the greater the chance for errors and inefficiencies. Regarding price methodologies, most reimbursements are based on CMS’ Average Sales Price (ASP) and/or Manufacturers’ Average Wholesale Price (AWP). This should be straightforward. However, payments, driven by a coding process […]

Each year there are dozens of new drugs (56 in 2018) and new CMS HCPCS assignments (38 in January 2018), as well as hundreds of new indications approved. This is in addition to the ongoing updates in coding assignments, pricing, generic entries and more. Consider that the average cost for a medically covered drug is […]

NDC mandates have been in place for Medicaid covered lives for over a decade. In recent years, this requirement has been expanded to account for additional lines of business. This shift creates a larger member population which in turn creates new claim volume. The addition of the volume mixed with the requirement for electronic claim […]

INSIDE THIS ISSUE Code Updates: Large Price Changes Reminder – NEW HCPCS Q-Codes effective July 1, 2018  CMS NEWS: April 1, 2018 NOC Pricing File Updated Drug Reimbursement Code Price Updates  Drugs/Devices: New Clinical and Billing Information New Webinar: Shedding Light on Medically Covered Specialty Drug Pricing Methods Let’s discuss Specialty Drug Pricing Methods… WAC. […]