Each year there are dozens of new drugs (56 in 2018) and new CMS HCPCS assignments (38 in January 2018), as well as hundreds of new indications approved. This is in addition to the ongoing updates in coding assignments, pricing, generic entries and more. Consider that the average cost for a medically covered drug is +$200 (Client Claims data). Errors associated with the processing of these claims have significant implications. Data quality must be monitored and updated into processes and systems to avoid these risks. This is compounded by the challenge of infrequent updates to the pricing methodology or coding assignments. Most organizations make updates quarterly or semiannually; however, the provider market is aware of the same updates more frequently and is often seeking these updates as part of a claim review. This is where data gaps of up to 9 months can reduce the effectiveness of cost controls. Without rigorous governance over these innovations and updates, the impact of these coding complexities can create significant expense implications in a short period.
The above excerpt is from “Automated Controls for Medical Drug Spend” by RJ Health’s Chief Innovation Officer, George Herchenroether.
Appropriate reimbursement for drugs covered by the medical benefit requires more data and structure than most medical claims or billing systems were originally intended to process:
If you found this information about medically covered drugs helpful, you may also like to register for our upcoming webinar, Creating Pre-Payment Controls for Medically Covered Drug Costs through Automation.