RxI Services

The Issue
The cost of specialty pharmaceutical s is projected to exceed $60 billion annually by the end of this decade – with some 100 biopharmaceuticals from more than 70 manufacturers awaiting FDA approval in the pipeline. Although health plans recognize the need to mitigate these costs, the complexities of the contracts, technology limitations and lack of standardized codes has left payers with the difficult task of accurately assessing complex, high dollar claims under ambiguous reimbursement methodologies, resulting in an environment where unit integrity and accuracy cannot be verified. Thus, the majority of overpayments are the result of billing errors relating to high-cost injectable medications that necessitate improved cost management strategies.

The Solution
Healthcare payers now can control the rising costs associated with reimbursement of prescription injectable medications in physician and other outpatient settings through Viant’s unique RxI Services. Viant has developed a series of pharmacy cost management services designed to support many of the nation’s leading health plans. These unique services help manage high cost injectable and specialty pharmaceuticals in care settings such as oncology, physician, home infusion and renal dialysis through validation of the clinical, contractual and financial components of a claim. RxI Services consists of experienced pharmacists, nurses and contract audit professionals who understand the complexities of claims systems, reimbursement methodologies and clinical service issues. Viant reviews over $1 billion in specialty claims annually.

The Value

• Proprietary technology to screen high volumes of claims and check for clinical appropriateness of dosage and quantity of drug billed relative to days supply
• Specialized clinical expertise familiar with dosing, package and pharmaceutical calculations
• Verification of actual physicians order, validating drug, dosage, frequency and length of therapy if necessary
• Elimination of unnecessary oversupply and wastage of high-cost medications
• Enhances contract and fee schedule language to address potential overbilling of units

How It Works
RxI Services uses experienced clinical pharmacy staff, auditors and proprietary technology to identify and validate actual physician orders and units of medication when indicated. This validation process allows Viant auditors to perform exact pharmaceutical calculations, reconcile correct product and package size and verify correct units of high-cost drugs billed. Once correct orders and units are validated, accurate pricing of claims to any variety of applicable fee schedules or reimbursement methodologies can be accomplished. RxI’s audit and repricing results also help payors incorporate new contract language to contain costs for these specialty products and services going forward.

Advantages

• Claim reviews performed by specialty auditors experienced with high-cost injectables and other specialty services
• Expertise validates clinical dosing, unit and correct package size and verification of contract terms and pricing
• Pre-payment repricing option: automated screening process to filter those claims with high potential for payment error then validate and reprice the claim before it is paid
• Post-payment recovery option: savings identified from the audit process can be recovered by either offset or collection methods
• Audit experience with over $1 billion in specialty claims reviewed annually

Summary
RxI Services provides the most comprehensive review to validate the clinical, contractual and financial components of claims associated with high-cost injectables and other specialty services and can be performed before or after a claim is paid. To learn more about Viant’s RxI Services, call us today at 800.820.5824.