For 2008 alone, the pharmaceutical insurance industry became massive with over 3.8 billion drugs costing 291 billion dollars for prescription medication revenues. Governments (Federal, State & Local) run the main drug care programs in the United States, led by private insurance providers, self-insured businesses, and employers.
PBMs send out invoices on about $11 trillion in drug statements per two (2) weeks. Such pharmaceutical invoices are usually billed in the fourty-eight (48) hour time period provided for most PBM contracts without scrutiny. Benefit Managers strive to perform their fiduciary duties to maintain correct accounting, but they still found it difficult to check the tens or even hundreds of thousands of claims for each invoice before payment… Too good.Learn more about them at CobaltRx.
Despite leverage growing on businesses as well as the government’s legislative and executive branches, corporate profit backers, it’s a foregone conclusion that the public would expect more accountability for PBM operating practices. While other human resource experts and pharmaceutical advantages specialists are seeking to co-opt PBMs to achieve deals on prescription costs by collective negotiations and longitudinal PBM evaluations, one firm has arisen that has made it their task to insure that PBMs first and foremost perform up to their contract terms. Negotiations over contracts are not necessary until you are sure the deal would be upheld.
Pharmacy Says Analytics (“PCA”) is a new trend within health information management firms. This emerging development industry offers supporters of pharmaceutical benefit programs with technical solutions to execute PBM arrangements, check consistency of invoice costs and maintain compliance for PBM. These services offer PBM compliance mechanisms by requiring pharmaceutical benefits payers to verify the authenticity of 100 percent of the reports on their PBM invoices prior to payment of the invoice. This basically offers an analysis of PBM in real time by supplying the invoice for mistakes with a pre-payment check. PCA development providers help pharmaceutical benefits payers to reduce fraud and misuse, take track of rising Pharmaceutical Benefit Manager (PBM) costs and satisfy regulatory enforcement criteria for Sarbanes Oxley (SOX), HIPAA, Medicare Part D and FTC Red-Flag.
Pharmacy Claims Analytics services will have at least: 1) Study of 100% of PBM invoiced pharmacy claims 2) Self-directed invoice upload and automatic monitoring results 3) Web-based Application Service Provider(‘ ASP’) platform 4) Prospective Dispute Study (completed prior to payment of the PBM invoice) While other businesses provide eligible and triggered manual examination of claims.