Announcing ClaimGUARD Protecting AAP Members Against Underpaid Reimbursements
Underpaid reimbursements for generic prescriptions are a top industry concern and a top priority for American Associated Pharmacies (AAP). AAP Members have shared their experiences and voiced their own concerns over revenue loss and the “hoops they must jump through” to file these claims.
In response, AAP’s Managed Care division (United Drugs) has developed an automated under paid claims program, ClaimGUARD, that monitors claims data from over 400 Member pharmacies to proactively research below cost reimbursements on the Members behalf. To give an example of the potential financial impact, ClaimGUARD has increased MAC reimbursements across our Comprehensive Managed Care network for a seven week period throughout September and October totaling $89,391. The weekly ranges are from $234 to $35,196 with a seven week average increase of $12,770 to the AAP Managed Care network.
The above dollar values do NOT include potential increased margin for those stores who could adjust their U&C pricing, fix adjudication errors or improve purchasing and product choices. Managed Care prescription claims data shows that in many cases, a loss could have been prevented had the product been purchased from Cardinal Health or through the Member owned API warehouse.
Beyond MAC reimbursements, ClaimGUARD has identified prescriptions that are paid below cost due to:
• U&C is less than MAC rates
• U&C is less than contracted price
• Wrong DAW codes where used
• Days Supply or other SIG code issues
• Products were available at a better cost of goods
• Using the “wrong” products, (tabs versus caps) or NDC
The volume of both manually submitted (fax) and automated claims continues to grow. The AAP Managed Care department reports submitting in excess of 500 claims weekly for pricing
review/response and will continue to add additional BIN’s to the ClaimGUARD automated process.
Members with “self-imposed” pricing issues will be notified and educated by their AAP Territory Manager.
Many of the most common issues can be corrected with remedies such as:
• Understanding of pricing (U&C)
• Ensuring pharmacy dispensing systems have up to date AWP files
• Thoroughly reviewing prescriptions prior to adjudication
• Properly inspecting screens during the dispensing process
• Consideration of a pre/post editing program available through a switch vendor
Today, Managed Care receives reimbursement inquiry requests by fax or through the United Drugs website when a Members’ costs of goods are greater than the reimbursement for PBM’s, insurers, TPA, and other third party payers. Typically third party payers won’t respond to a MAC price increase request until complaints grow to a critical number, and even then PBM response times to review requests vary from days to months. With ClaimGUARD, claims identified as “Paid at MAC” will be re-submitted for review, while claims identified as “Paid at Contract” will be forwarded to an AAP Managed Care Senior Contract Manager to be used in negotiations as illustrations and verifications of existing reimbursement rates that may not be sufficient.
Another ClaimGUARD component is coordinated involvement with Cardinal Health and direct manufacturers (via the Member owned API warehouse) to evaluate and modify, when applicable, the acquisition cost of goods. Additionally, API will actively notify the United Drugs office of changes whereby United Drugs can notify the PBM’s and third party payers when purchasing price increases occur. AAP’s goal is to shorten the time between a manufacturer’s published price increase and a necessary published MAC price increase.
As ClaimGUARD continues to grow and develop, all automated and manual responses will be integrated. Beginning in November, AAP will communicate on a regular basis the increased dollar value of successful MAC and item cost changes, as well as the medications affected. Once program development has been fully realized, the Members will have a best in class automated system designed to support Members profits and operations. This is our pledge to you, the Members and owners of AAP!
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