HOW-TO CLINIC: RX CONTRACT MANAGEMENT & AUDIT FOR PHARMACIES

Transcription

1 HOW-TO CLINIC: RX CONTRACT MANAGEMENT & AUDIT FOR PHARMACIES Chris Smith, R.Ph Director, Pharmacy Business Intelligence Inmar Sandy Atchison Senior Product Analyst

2 Contract Management App 2

3 Savings history: Furnishes one location to store adjustment records, providing forecasted and actual savings achieved for business-case justification. User-defined business analytics: Provides expanded summarization and filter options for more customizable information. Exceptions workflow: Supplies automated flags based on your specific criteria to alert you of opportunities regarding exceptions and potential savings. Contract Management Fundamental Components Contract level metrics: Enables you to drill down to review gross profit per carrier contract. Contract database: Equips you with one location to house all of your contracts, including the data and image of paper contract typically a nightmare to keep these complex records in order. Contract modeling: Delivers the unique ability to run what-if scenarios through user-friendly wizards to determine profit impact of contract changes. 3

4 Contract Management value Accurate billing by identifying necessary dispensing system correction. Purchasing by negotiating generic cost savings. Fee management by comprehensive view of DIR, transaction and discount card fees. Pricing decisions through U&C strategy and discount drug list management. Contract negotiations with visibility into payer trends and benchmarking, discount drug programs and more. Corrected pharmacy operations when not dispensing preferred drug. Benchmarking reimbursement rates to the industry to identify opportunities. Reimbursement exceptions through MAC appeals, generic inflation control and carrier system corrections. 4

5 Contract Management: Success stories Improved generic reimbursement basis points, realized over $300K when researching carrier adjustments Improved store procedures $10M, identified stores dispensing non-preferred drugs/incorrect DAW and implemented system edits Reduced procurement costs Recognized highly dispensed drug paid below margins, used data to negotiate 50 percent cost decrease Market conditions Recognized drug with limited availability, negotiated reimbursement, increased saving $500K AWP rebilling $25K reimbursement increase from AWP re-bills to government plans not accepting electronic rebill Contract negotiations Visibility into pharmacy operations, trends and benchmarking of payers, discount drug programs and more Improved Brand Reimbursement $23K savings from brand claims paid below contracted rate 5

6 DEMO 6

7 Q&A Questions 7

8 Audit App

9 What are you experiencing? Audit Management How many audits do you receive? What is the average value? What turnaround times are you required to meet? Do you have trouble with these? How do you validate that take-backs were what you agreed to? How successfully are you negotiating recoupments down? How do you access older data when audited? How successful are you at re-billing to prevent audits or adding more dispensing controls? Have you identified any triggers for audits? How many $ are at risk annually from audits? How much time do you spend managing each audit? How do you keep audit records? Do you have record- keeping challenges? 9

10 Audit Management app Client receives audit notification from payer App identifies trends and triggers for BI to prevent future audits Audit Audit Management Management App App Audit information is entered into web app and claims are attached Client negotiates audit and system monitors the takebacks 10

11 Audit reporting: Robust reporting tool for summary or transaction-level reporting with many filters and summary options. User-defined business analytics: Provides summarization and customizable filters for onscreen metrics. Audit Intelligence: Document audit triggers to mitigate future audits by implementing pharmacy system pre-edits, educating to improve store compliance. Audit Management Technology Components Audit-level metrics: Workflow enables timely response and action. Onscreen metrics to identify atrisk amounts. Audit master data: Manage client-level discrepancy codes, audit status descriptions, audit vendors lists and specialist lists. Audit detail: On-screen view of detailed audit record, including claims associated with an audit. Ability to assign tags, discrepancy codes to claims. Flag claims approved for recoupment. 11

12 Value Value description Annualized value Increase revenue and profitability Through negotiation, reduce audit take-backs and prevent future audits. Improve current recovery rate; clients report as much as 98 percent recovery rate Audit Value Proposition Reduce bad debt Reduce risk Lower costs Improve patient outcomes Single source solution Minimize audit take-backs and validate actual recoupments against negotiated amounts. Track audit triggers and add dispensing checks to prevent audits, review potential audit risks 24 hours following fills, and maintain comprehensive records. Reduce IT infrastructure costs, audit specialist resources and improve efficiencies through BI tools and automation. Reduce pharmacy audit risk and subsequent patient pay increases. Manage all claims receivable types (third-party, cash, discount cards, AWP resubmission claims, professional services, specialty and patient receivables) and audit trends in the same platform as reconciliation and contracting. Greater visibility and collaboration Maintain comprehensive records and product management reports

13 DEMO 13

14 Questions? 14

15 Chris Smith, R.Ph Sandy Atchison

16 Click the survey button found on the session page.

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