Pro Pharma Announces Solutions for Medicare/Medicaid Managed Care MAC Pricing

Oversight/Monitoring of Medicaid/Medicare benefits requires timely interventions, including MAC compliance with State Medicaid MAC and the federal FUL. Part D variance in claim adjudication/non-compliance must be corrected faster to avoid unnecessary penalties.

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

Medicaid is auditing generic drug payments and, in many cases, crediting capitation rates for claims paid above the Medicaid MAC rates. Medicaid is also auditing claims paid with an AWP above the statutory definition of WAC*1.2. In all cases Medicaid is auditing per claim.

Medicare is auditing for valid NDC numbers (National Drug Code) and audits for valid physician identifiers (DEA or NPI) is imminent. Medicare is also auditing claims on a per-claim basis for payments consistent with the Medicare MAC, also known as the Federal Upper Limit, or FUL. Health Plans are being scored based on compliance with Medicare benefits, claims payments, etc.

The bottom-line is that audits continue to expand and cover a wider scope. Medicaid and Medicare are less likely to negotiate audit findings than third party payers. As a result, oversight and monitoring of your Medicaid and Medicare benefits requires more timely interventions, and non-compliance must be corrected faster to avoid unnecessary penalties.

Pro Pharma helps you to comply with Medicaid and Medicare benefits as close to real time as possible; namely, at the PBM invoice payment. You don’t have to wait for reports from CMS, or Medicaid and Medicare audits to find out what is wrong.

Pro Pharma’s Invoice Screens™ audit all elements of eligibility, benefit compliance, claim validity and re-priced payment validation pre-payment. This includes compliance with J Code payments for Part B and D drugs using Pro Pharma’s JCode Calculator™.

In addition Pro Pharma’s pre-payment audits cover MAC compliance with State Medicaid MAC and the federal FUL. And Pro Pharma’s Part D Workbook tracks all elements of Part D every invoice, every month, every quarter, and every year to ensure that you are aware of Part D non-compliance in claim adjudication almost as fast as it happens.

Bottom-Line: Pro Pharma’s Invoice Screens™, JCode Calculator™, MAC Analyses™, and Part D Workbook™ put you in the driver’s seat for oversight, corrective action planning, and implementation of changes for your Medicaid and Medicare books of business. At a cost of pennies PMPM, transparency is in your hands.

Pro Pharma has developed Invoice Screening™ to assist Providers, Physicians, and Pharmacies with management of rejected Rx claims that did not meet contract requirements pre-adjudication by:

1. Collecting dollars from inappropriately paid Pharmacy Claims

2. Correcting Pharmacy Claims payment process of vendors

3. Controlling provider “abuse”

About PRO PHARMA

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™, 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.