Pro Pharma Announces Efficiency Adjustments Cause Heartburn for Health Plans

NORTHRIDGE, Calif.--(BUSINESS WIRE)--Pro Pharma Pharmaceutical Consultants, Inc., a pharmaceutical consultant organization which focuses on data analytical expertise, announced today that enhanced Invoice Screening™ is now available to assist with Accounts Payable reviews of Health Plan, PBM and TPA invoices; which is performed weekly, biweekly, monthly or less frequently. It also includes True Out-of-Pocket Cost (TrOOP) validation.

Medi-Cal in California is applying Efficiency Adjustments to the pharmacy capitation payments for health plans servicing Medi-Cal patients. These adjustments implicate generic payments greater than the rate that Medi-Cal would pay for the same prescriptions. Other States are applying Efficiency Adjustments to clinical edits in an effort to improve quality and decrease costs to the State. Due to the poor financial situation of most States, according to Pro Pharma, efforts to control costs by discounting capitation payments are expected to expand. Yet, there are options and opportunities for the affected Health Plans.

There are tools in place to provide plans with program information so that they can discuss cost savings options before State efficiency audits cause them to experience reduced capitation rates, with their Pharmacy Benefit Consultants and/or Pharmacy Benefit Managers (PBMs). This includes:

Drug pricing consistent with the statutory definitions of AWP
Generic pricing consistent per-claim with Medicaid, Medi-Cal and Medicare rates
Claim validity checks before denials by the State or CMS

To achieve savings these options must be available at point of invoice payment so that Finance Departments can ensure compliance with State and Federal payment guidelines. Essentially, the Accounts Payable Department, or function, must be able to audit pre-payment. Using current technology - Invoice Screening™ and MAC List Customization/Maintenance, this is possible and is currently being performed in both public and private health plans.

Pro Pharma currently supplies Accounts Payable Departments with pre-payment pharmacy claims Invoice Screening™ that addresses all issues discussed above, and allows Health Plans to make appropriate cost saving decisions.

Please use this information to work internally to develop possible strategies to correct medical claim deficiencies before Medi-Cal reduces your capitation.

Please visit www.propharmaconsultants.com for more complete information.

About PRO PHARMA PHARMACEUTICAL CONSULTANTS, INC

PRO PHARMA is a multi-service, woman owned, privately held consulting firm offering a vast portfolio of services to public and private entities including self-insured employers, Taft Hartley Trusts and unions, public employers, for-profit hospitals and integrated health networks, health care insurance companies, worker's compensation insurers, small-to-medium sized HMO's, and physician groups.

As a primary service to plan sponsors for achieving below trend results, PRO PHARMA provides an integrated program of administrative process improvements, clinical quality oversight, and provider/member education.

PRO PHARMA’s Consulting services are grounded in the use of data and the communication of that information to define benefit trends, drivers and other analytical indicators. PRO PHARMA markets Biotech Modeling™, Invoice Screening ™, JCode Calculator™, Quality Management Program™, Pro Pharma RFP™, Financial, Performance & Claims Audits™ and Treatment Calendar™. The Company directly markets its products in the U.S. and collaborates with partners to reach international markets.

About Quality Management Program™ (QMP):

The QMP is a multi-faceted approach that attacks the pharmacy benefit cost and quality from multiple directions; namely, physician prescribing decisions, member demands, pharmacy oversight and patient education, HR rep education, and messaging to actives/retirees. The program is directed to giving patients and physicians the tools to make better purchasing decisions that expand member co-pay dollars. The bottom line is: payers (self-insured, employers, Trusts, etc.) lower their pharmacy trend.

About Invoice Screening™:

About 10% of drug spend is being paid from PBM Invoices, and should have been rejected by clients prior to payment. Pro Pharma’s Invoice Screening™ analyzes invoices against: formulary compliance, compliance with MAC pricing, eligibility, claims pricing, invalid claims, and excluded benefits.

About JCode Calculator™:

Pro Pharma has developed a Standardized Injectable Fee Schedule to assist with the management of claims payments. The advantage to this product is that it bases all Injectable reimbursement on AWP cost, and can be customized for drug category discounts or multiple discounts based on drug type or specialty. It includes at least one AWP for every HCPS Code and CPT code description; NDC, brand name, generic name, strength, package size, etc.

For more information about PRO PHARMA, please visit www.propharmaconsultants.com.