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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:
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.
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.
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
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.
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.
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.
RJ Health Systems’ subject matter experts can provide a targeted consultation on improving workflows and build operational processes for specific departmental issues.
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.
Recommend patient shift opportunities with rationale from Outpatient to less costly settings.
Develop Provider scorecards for monitoring and determining the likelihood of waste and abuse across the network.
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