A proactive medical necessity review program reduces revenue loss associated with outpatient medical benefit drugs.
Purpose A common denial trend that occurs with "outpatient medical benefit drugs" (ie, medications covered by a medical benefit plan and administered in an outpatient visit) is payers not requiring or permitting prior authorization (PA) proactively, yet denying the drug after administration for medi...
| Publicado en: | American Journal of Health-System Pharmacy Vol. 78; no. 17; pp. 1591 - 1600 |
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| Autores principales: | , , , |
| Formato: | algorithm tables/charts Journal Article |
| Publicado: |
Oxford University Press / USA
Sep2021
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| Acceso en línea: | Ver este registro en EBSCOhost |
| fields | @attributes: recordID: 1 pdfLink: plink: https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=152206481&site=ehost-live header: @attributes: shortDbName: ccm uiTerm: 152206481 longDbName: CINAHL Complete uiTag: AN controlInfo: bkinfo: dissinfo: jinfo: jid: 10792082 1X3 jtl: American Journal of Health-System Pharmacy issn: 10792082 maglogo: N pubinfo: dt: Sep2021 vid: 78 iid: 17 pid: 622 pub: Oxford University Press / USA artinfo: ui: 152206481 152206481 152206481 10.1093/ajhp/zxab046 152206481 ppf: 1591 ppct: 9 formats: fmt: – @attributes: type: T – @attributes: type: P tig: atl: A proactive medical necessity review program reduces revenue loss associated with outpatient medical benefit drugs. aug: au: Hawes, Emily M Misita, Caron P Amerine, Lindsey B Francart, Suzanne J affil: University of North Carolina (UNC) School of Medicine, Department of Family Medicine, and UNC Eshelman School of Pharmacy , Chapel Hill, NC, USA sug: subj: Outpatient Service Cost Benefit Analysis Drugs, Prescription Economics Program Evaluation Pharmacy Administration Medicare Economics Reimbursement Mechanisms Insurance Coverage ab: Purpose A common denial trend that occurs with "outpatient medical benefit drugs" (ie, medications covered by a medical benefit plan and administered in an outpatient visit) is payers not requiring or permitting prior authorization (PA) proactively, yet denying the drug after administration for medical necessity. In this situation, a preemptive strategy of complying with payer-mandated requirements is critical for revenue protection. To address this need, our institution incorporated a medical necessity review into its existing closed-loop, pharmacy-managed precertification and denials management program. Summary Referrals for targeted payers and high-cost medical benefit drugs not eligible for PA and deemed high risk for denial were incorporated into the review. Payer medical policies were evaluated and clinical documentation assessed to confirm alignment. This descriptive report outlines the medical necessity workflow as a component of the larger precertification process, details the decision-making process when performing the review, and delineates the roles and responsibilities for involved team members. A total of 526 drug orders were evaluated from September 2018 to August 2019, with 146 interventions completed. Of the 761 individual claims affected by proactive medical necessity review, 99.2% resulted in payment and less than 1% resulted in revenue loss, safeguarding more than $5.3 million in annual institutional drug reimbursement. At the time of analysis, there were only 3 cases of revenue loss. Conclusion Our institution's pharmacy-managed medical necessity review program for high-cost outpatient drugs safeguards reimbursement for therapies not eligible for payer PA. It is a revenue cycle best practice that can be replicated at other institutions. pubtype: Academic Journal doctype: algorithm tables/charts Journal Article ougenre: Article language: English refInfo: holdings: @attributes: islocal: N |
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