The prescription claims process often feels like a mysterious black hole in the healthcare universe, hiding valuable insights for plan sponsors. Let's embark on an enlightening journey from the patient and prescriber to the pharmacy, the switch, the Pharmacy Benefit Manager (PBM), and those elusive manufacturer buy-downs. Follow the data pathway and understand who has their hand in the pot.
Patient/Prescriber: Our data-driven journey begins with the patient and their prescriber. A script is created with the patient's details, the medication, dosage, and the doctor's instructions, which are the first nuggets of valuable data.
Pharmacy: The pharmacy is where the magic happens and where data starts to accumulate. A pharmacy employee deciphers the prescriber's handwriting, verifies insurance details, and adds their own notes to the script.
The Switch: The switch operator plays a pivotal role, acting as a secure gateway that transmits prescription claims data between the pharmacy and the PBM. (They may even be silently exchanging some of this information with manufacturers without alerting the PBM). The data transmitted by this covert courier is not always visible to plan sponsors.
Claims Processing System (PBM): The PBM is the data maestro. They verify the prescription, confirm insurance coverage, and even sprinkle in some financial magic with manufacturer rebates their GPOs (Group Purchasing Organizations) collect. Side note: large amounts of these manufacturer to GPO money exchanges happen overseas making them difficult to track, while lowering the tax burden for the PBM-owned GPOs. All the while, PBMs are gathering valuable data insights, which are not always fully transparent to plan sponsors.
Secondary Claims, Including Manufacturer Copay Assistance: Secondary claims introduce an extra layer of complexity. These claims come into play when a patient is covered by multiple insurance plans. Primary insurers play a leading role, covering the primary part of the claim, while secondary insurers (including manufacturer copay assistance) step in to support any remaining costs. Plan sponsors need to have a comprehensive understanding of their prescription claims data, including these secondary claims, to be a good fiduciary of their plan.
Rejected Claims: Rejected claims, depending on the rejection code, could end up in many different parties’ hands: the pharmacy, the provider, and occasionally, the manufacturer. Plan sponsors need to follow the rejected claims, understand why they were rejected, and use those data insights to improve their benefits offering.
Claim Resubmission: When a claim is rejected, the pharmacy may adjust the prescription claim and resubmit it. However, it’s not always clear to the pharmacy what the next steps are to help the patient get their prescription.
Pharmacy Wholesalers: Pharmacy wholesalers directly supply medications to pharmacies. The most substantial and lucrative wholesalers are often under the ownership of the same corporate entities that also own pharmacies, switch operators, as well as other companies sharing your claims data. Hello again, vertical integration! Wholesalers price drugs using a different pricing structure than what plan sponsors typically see in their pharmacy claims data. Oh, and they provide rebates back to the pharmacies as well.
The Patient Out-of-Pocket Expense: All these twists and turns in data navigation can result in a casino-like experience for the patient when they ultimately pick up their medication at the pharmacy—the price can be different for every drug, for every patient, at every pharmacy. In fact, a third of paid claims are left at the pharmacy and never picked up by the patient—the number one reason is cost.
Plan sponsors, you own your prescription claims data and want to work with partners who are aligned with your goals. While patients and plan sponsors are the ones funding the prescription system, it’s the players inside who are collecting the profits.
At Scripta, we don’t own a pharmacy, switch, wholesaler, PBM or any other piece of the claims’ process. We’re a completely independent unbiased partner working on behalf of our clients and their members. Let us arm you with the insights & analytics you need to see inside your prescription claims.
Scripta Savings Strategies:
Get as much of your data as you possibly can: Ask your consultant to go deeper than your PBM data, capturing and providing all parts of your claims’ data exchange. If unsuccessful, consider working direct.
Don’t fall in love with your rebate check: Rebate checks are like getting a tax refund at the end of the year. It feels great, but the money was yours in the first place. Even worse with drug rebates, your sickest plan members are the ones footing the bill for those high rebate checks.
Ask your vendors to disclose all sources of revenue for their company: Consider working with partners who have aligned incentives with you and whose only source of revenue is a direct employer-to-vendor transparent fee.