Profitable New Service for Auditing PBM Claims
In addition to providing software solutions to its clients, DataPath at times recommends other services or software that their clients may find useful and profitable. Accordingly, DataPath is now happy to recommend RxAnalyzer™, an audit service (developed by Agelity, Inc.) designed to audit Pharmacy Benefit Manager (PBM) claims.
A Profit for You . . .
You can use this service to make a handsome fee and, perhaps even more profitable, to blow open doors of larger potential clients. Even if you have not been rendering services in the mid-to-large employer space, you can use this service to get your foot in the door. Once in the door with this service, the employer will most assuredly listen to anything else you might tell them. This service is that POWERFUL!
And a Benefit for your Clients.
The PBM industry has no oversight committee (such as the SEC in the Securities Industry), and remains virtually unregulated and unchecked. This lack of oversight creates an environment a PBM might be able to take advantage of— until now! With RxAnalyzer™, a PBM client can independently verify the pricing of each and every one of their pharmacy claims. Claims adjudicated outside the terms of the client’s contract and resulting in an overcharge are identified and presented in clear and concise reports to be presented to the PBM for restitution.
How RxAnalyzer™ Works.
RxAnalyzer™ licenses and deploys the same industry drug databases PBMs use to determine the Average Wholesale Price (AWP) for each FDA-approved drug. (Just keep in mind that AWPs change frequently and a pricing database must be maintained accordingly.) With AWP as the common denominator for each pharmacy claim, RxAnalyzer™ can apply the terms of the client’s contract to AWP to determine if the PBM is adjudicating the pharmacy claims correctly.
RxAnalyzer™ Audit Reports include:
- Client Profile: Report stating the PBM contract terms.
- Claims Summary: Report identifying the number of claims in each category (such as brand, generic, and mail order).
- Price Summary. Report identifying the cost of claims in each category (such as brand, generic, and mail order).
- Overcharged Detail: Report listing every overcharged claim with enough detail (such as pharmacy, prescription number, date filled, and drug number) to challenge the PBM.
How Others Have Profited.
Those who attended the DataPath Annual Conference this year will remember the success stories related by Gunnar Marich in his RxAnalyzer™ presentation. A typical success story revolved around someone presenting a proposal to a large company with a self-funded plan, offering to audit the PBM claims for the past few years for a percentage of the recovered claims —that's right, no charges, just a percentage. This offer proved an amazing windfall! This story has been repeated over and over again.
Through RxAnalyzer™, Plan Service Providers (PSPs) can add a very profitable service to offer their clients, and organizations can analyze their pharmacy claims on an ongoing basis to detect overcharges.
Click here for more information about RxAnalyzer™ and see how it can work for you.