As pharmaceutical services continue to grow within Medicaid, states are working hard to curb the increased costs associated with providing prescription drug coverage.
To help control pharmacy spending, HMS offers solutions that:
» Intervene daily and directly with pharmacist —before a claim is paid
» Reduce the need for pay and chase
» Allow providers to correct erroneous claims
» Minimize future audits
» Significantly minimize appeals by avoiding audits
We offer a full range of services—from real-time coordination of benefits to desk, onsite and in-depth investigative audits.
Our robust services are most effective as an integrated tool set that includes:
Real Time Cost Avoidance
Pre-Pay solution to help you avoid paying pharmacy claims when there is other coverage and return the third party coverage information to the provider so the provider can bill the claim correctly.
Post-Adjudication solution to intercept the claim from the point-of-sale or adjudication system, stop payment, and immediately redirect claims to the liable third party.
Pharmacy Audits are a critical part of any program, and may be the only safeguard against pharmacy fraud, billing errors, and patient/physician abuse. HMS audits 100% of claims via desktop, and selectively chooses claims for on-site audits. If warranted, we perform three- or four-day focused reviews. We are the only company that intervenes directly with pharmacists in real-time before a claim is paid to reduce the risk of future audits.
Our Pharmacy Audits provide recoupment of payments, provider education, fraud detection, and fraud deterrence. They can be customized to meet client needs, ranging from simple, routine credentialing audits to desktop programs that use the latest database and modeling technology.
Pharmacy Benefit Manager (PBM)/Claims Processor (CP) Audits, which examine and evaluate the operations and procedures of the PBM/CP. PBMs/CPs handle millions of claims in real time without manual intervention. Errors in this process can cost health plans billions of dollars.
As an independent auditor, our clients never need to be concerned about conflicts of interest inherent in processing and auditing the same claims. Our PBM/CP Audits ensure accurate administration; establish performance benchmarks; and educate PBMs/CPs on expectations for administration.
Rebate Audits, which assist in ensuring that a sound and timely rebate process exists. We examine and evaluate the operations and procedures of the PBM/CP to verify the accuracy of a client’s Rebate administration, establish performance benchmarks, and educate the PBM/CP as to the client’s expectations. Our system of checks and balances ensures adherence to rebate contract guidelines, which have grown more complex in recent years.
From a financial perspective, HMS can help to ensure that rebates on claims with billing or adjudication errors are minimized. From a clinical perspective, we can help identify areas where rebates are being applied to prescription claims outside the normal guidelines.
Only HMS's single-door, program integrity solution offers a comprehensive approach to identify overpayments, increase recoveries, and prevent future overpayments.
