Category Archives: Industry Insights

New Drug Overview – galcanezumab-gnlm (Emgality™) On September 27, 2018, the U.S. Food and Drug Administration (FDA) approved galcanezumab-gnlm (Emgality™) for the preventive treatment of migraine in adults.  Galcanezumab-gnlm is the third calcitonin-gene related peptide antagonist to be approved for this indication this year after fremanezumab-vfrm and erenumab-aooe, approved on 9/14 and 5/17 respectively.  According […]

INSIDE THIS ISSUE Code Updates: Update – New Q-Code Effective October 1, 2018 and July 12, 2018 Reminder – New C-Codes for Hospital OPPS use Effective October 1, 2018  CMS News: Medicare Influenza Vaccine Pricing 2018-2019 Season NEW Influenza CPT® Code 90689 Effective January 1, 2019  Drug Reimbursement Code Price Updates  Drugs/Devices: New Clinical and […]

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 […]

Many medically covered drugs are costly, and processing errors can have significant implications. By 2020, it is estimated that more than half of specialty drug claim costs will be submitted through the medical benefit. Join Wendy Sullivan, Director of Data Informatics, on October 11th, 2pm EST, as she walks through the common issues and solutions […]

In September there were a total of six new drug approvals by the FDA we deemed specific to the specialty market. In addition, there were two supplemental drug approvals. The FDA had assigned six new products for review. Finally, there was one complete response letter with no current data on expected resubmission date. Drugs included […]

FDA Approval: 9/14/18 Migraine is a debilitating disorder that affects millions of people in the United States. Migraine can affect individuals in a way that deprives them of their normal, daily activities, and often results in pain, physical impairment, lost productivity, and increased financial cost. Fremanezumab-vfrm, developed by Teva Pharmaceutical Industries Ltd., is a fully […]

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 […]

FDA Approval: 9/13/2018 Hairy cell leukemia (HCL) is a rare, slow-growing cancer of the blood in which the bone marrow produces too many abnormal B cells or lymphocytes. This compromises the bone marrow’s ability to produce healthy blood cells and platelets. Patients with HCL may experience enlargement of the spleen, increased susceptibility to life-threatening conditions […]

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. This applies even more so when the systems are proprietary. The tendency to solve this issue has been to apply headcount (ex- case workers & analysts), continually enhance existing […]

Medically covered drug pricing is highly sensitive, and changes occur frequently. The more variability in a system, the greater the chance for errors and inefficiencies. Regarding price methodologies, most reimbursements are based on CMS’ Average Sales Price (ASP) and/or Manufacturers’ Average Wholesale Price (AWP). This should be straightforward. However, payments, driven by a coding process […]