RJ Analytics

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Greater Transparency Into Your Medical Drug Spend

Increasing Healthcare costs continue to outpace inflation in the US.  Specialty drug costs are the largest driver and component of health care spend.  This surge has led to transformative patient care and given rise to a disproportionate total healthcare spend.

Major drivers of increasing medical drug spend for payors:

  • The complex processing of medical drug claims limits drug utilization review interventions and formulary management programs that payors rely on PBMs to control costs
  • Medical drug claims are typically reimbursed using multiple pricing methods driven by site of care; discounted basis, fee schedules, average sales price(ASP), etc.
  • Lack of granularity and transparency in the HCPCS billing system causes healthcare organizations to pay higher than expected costs under the medical benefit
  • As new drugs hit the market, we see an increase in variations of contemporary drug therapies vs standard of care that may lead to volatility

Our Mission

RJ Analytics provides greater transparency into medical drug spend, ultimately putting you ahead of rising healthcare trends. We supply our customers with data driven solutions to make informed decisions while improving the health and well-being of patients, and achieving cost efficient results.

Our goal is to partner with health plans to create insight and develop methods to support the effective management of healthcare trend and spend across their organization. Our dynamic team of Clinical Analysts and Data Scientists work with our customers to create actionable data and provide transparency in to coding, pricing and clinical indications.

  • Lower the risks of overpayment for medical specialty drugs
  • Create mitigation plans to control fraud waste and abuse
  • Develop fee schedules and define consistent payment methods
  • Gain current insightful specialty drug intel by therapeutic class
  • Manage patient safety with appropriate dosing and utilization

What We Offer

Claims Data Integration And Discovery

We integrate client’s medical claims with RJ Health Systems’ Intel to provide a retrospective claims evaluation that assists in the identification of specific areas of risk and/or opportunity within the medical benefit payment process.

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Claims with potential overpayment

Pricing review identifies claims whose pricing is not aligned with current market of fee schedule rates.

Physicians and potential overpaid amounts

Pricing by NPI evaluates physician level claim submissions for the purpose of identifying overpayment and potential fraud, waste, and abuse.

Claims with an off-label diagnosis

An evaluation of claims against our drug diagnosis (ICD-10-CM and ICD-9-CM) crosswalk to identify potential off-label or experimental usage.

Claims exceeding maximum dose

An evaluation of submitted HCPCS units against maximum dosing levels to identify claims that exceed expected doses and quantify impact

Administration Codes

Evaluate administration codes associated with drugs to ensure appropriate codes are utilized.

Appropriate Code and NDC

Evaluation of claims data to ensure that submitted NDCs are properly aligned with submitted codes.

Prescriptive/Predictive Analytics and Insights

Our Clinical analysts will apply our methodology through data modeling and will provide insight on the causes of over payment and identify targeted recommendations on how to contain costs in the future.

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Dosage Maximums:

Provide a sensitivity analysis to define various dosage thresholds by disease state and/or therapeutic class

Prior Authorization Audit:

Review and recommend policy and procedure adjustments through drug-to-diagnosis analysis and/or post-authorization validation.

Medical Claim Unit Crosswalk and Conversions:

Assist in the design and enforcement of NDC mandates and/or the resolution of billable unit discrepancies.

Consultation

RJ Health Systems’ subject matter experts can provide a targeted consultation on improving workflows and build operational processes for specific departmental issues.

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Fee Schedule Management:

Provide benchmarking against RJ methodology and recommendations for fee schedule optimization based on (i) actual allowed amounts vs. fee schedule and (ii) comparative reimbursement rates nationally / regionally.

Site-of-Care:

Recommend patient shift opportunities with rationale from Outpatient to less costly settings. 

Network Management:

Develop Provider scorecards for monitoring and determining the likelihood of waste and abuse across the network.

Benchmarking and Optimization

RJ Health Systems’ subject matter experts can provide a holistic consultation on improving workflows and build operational processes across your organization that contributes to managing medical drug spend on an ongoing basis

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  • Establish Key Performance Indicators from Prescriptive/Predictive Analytics and Insights and Consultation.
  • Determine internal and external benchmarks and milestones.
  • Refresh customized data quarterly and adjust accordingly

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RJ Analytics equips health plans with data driven solutions to make informed decisions while improving the health and well-being of patients, and achieving cost efficient results.