Pro Pharma’s Invoice Screening™ as a Management Tool for financial and clinical decision-making is available to clients on a fixed fee basis. Pro Pharma’s goal is to ensure that all identified savings are “due and payable” to our clients. The only percentage that Pro Pharma MAY be involved in would be as a percentage of “short paying” the PBM invoices, if clients have that ability in their contracts.
“This powerful and robust management tool integrates all facets of the benefit to provide a complete and comprehensive resource. This allows clients to look at the whole picture prior to making important decisions regarding the Pharmacy Benefit. Invoice Screens™ states Dr. Craig Stern, President of Pro Pharma,“solves problems, and NOT just identifies them! “
“Invoice Screens™ have proven to not only save money for our clients, but more importantly provide directed management information for decision-making and actions, in three (3) areas”:
• Management/Oversight of AP Function of the PBM.
states, Carol Stern, CEO of Pro Pharma Pharmaceutical Consultants, Inc.
Pro Pharma’s Invoice Screens™ look at the whole picture by encompassing the following Key Features:
• Reviews 100% of the claims invoices for accuracy
• Reviews PBM invoices which often contain significant overcharges
• Review all PRE-PAYMENT to PBM
• Allows Payers the ability to approve/disapprove payment for invoices before they make a payment
• Reviews ALL prescription claims for cost accuracy, eligibility, and other key metrics
• Turnaround time is 48-72 from receipt of complete data sets/invoices.
Implementation of Invoice Screens™ for reviews of Health Plan, PBM and TPA to provide an Accounts Payable oversight and management function of the PBM. This program is important as it provides valuable data and information for making daily, weekly and monthly management decisions that affect quality and cost.
Invoice Screening ™ eliminates payment errors, identifies problems previously unidentified or historically not addressed and puts money back in the organization’s pocket. Pro Pharma seeks to assist clients in minimizing their spending by identifying savings opportunities not commonly addressed by the PBMs. Pro Pharma will turn these reports back for management review/oversight/action within 72 hours after receiving complete data sets, to prevent payment rejections.
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. Invoice Screening™ is possible, using current technology, 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 strategize with your Management Team to develop methods and strategies to correct medical claim deficiencies before Medi-Cal reduces your capitation.
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™, 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.
About Rx MAC List™ (Pharmacy Maximum Allowable Cost™)
The Cost of Drugs is Skyrocketing. Pro Pharma develops and maintains customized MAC Lists for clients to help manage the effects of rapid and high increase of drug prices.
About Pro Pharma Suite of Tools™
Pro Pharma’s Suite of Tools identifies the cost and clinical issues for both Pharmacy and Medical, and formulates management plans and objectives to develop action plans to address “prescriptions for change.
About Biotech Modeling™
Pro Pharma utilizes both the Medical and Pharmacy paid claims to analyze previous claims experience and to develop a model to project future trends. These issues center on the need for drug specific claims information, processing rules to ensure accurate quantities and maximum payment amounts, and rules for processing miscellaneous claims. The model can be updated with enhancements expeditiously given new Medical and Pharmacy claims experience.
About Treatment Calendar™
Pro Pharma’s Treatment Calendar™ is a proprietary program comprised of Artificial Intelligence rule sets, which allow for quality and cost comparisons by peer-to peer, peer-to-best in class, peer to national norms, and peer to local norms.
Pro Pharma uses Clinical Protocols to analyze patient encounter data and diagnoses for required exams, tests, and medications. In this way, physician practices can schedule the applicable services for each patient and then review them for exceptions.
Please visit Pro Pharma Pharmaceutical Consultants, Inc. website for more complete information.