Challenge:

Our SNF partner lacked an efficient way to monitor pharmacy adherence to contract and plan limitations in real time.

An existing client of Empirian needed an effective method for which they could ensure their pharmacy was in complete adherence to their contractual guarantees from a pricing and dispensing perspective. Specifically, the facility was concerned that many of their charges were for prescription claims outside of the cost containment parameters that they requested the pharmacy support upon implementation. This particular pharmacy wished not to adjudicate claims in real time.

Solution:

Empirian took action to implement our Bill Review & Audit program.

Created specifically to solve the challenge this facility faced, our Bill Review & Audit program involves analyzing data retrospectively to assist our clients with managing pharmacy budgets, ensuring adherent dispensing, and working cooperatively with their pharmacy partners to remedy any identified concerns. Utilizing our customized claims processing tool, Empirian’s system supported all elements of the client’s pricing and plan design so that we could quickly and efficiently analyze their claims data and provide actionable reporting back to the client.

Results:

Skilled Nursing Facilities should be closely monitoring their dispense data.

Within the first quarter of involvement with the program, we identified that approximately 24% of the total claim utilization was billed outside of the established parameters set by the facility. While many were necessary, such as a high-cost drug approved by the DON or prescribing doctor, many were claims that could have been avoided or interchanged for a more effective option both clinically and financially. This facility group of approximately 30 facilities now realizes over $150k/year in savings by using the program.