Increased Scrutiny by Centers for Medicare & Medicaid Services Underscores Need for Rejection Analysis
MILWAUKEE, Aug. 13, 2012 /PRNewswire/ -- Recent civil money penalties levied by the Centers for Medicare & Medicaid Services (CMS) against a major Prescription Drug Plan (PDP) sponsor have hammered home the fact that CMS is not taking rejection analysis lightly. To help Medicare Advantage and stand-alone PDP sponsors respond to this new vigilance, TRICAST is offering a sound PBM oversight solution.
Primary Rejection Analytics
Rejection analysis and reporting is a crucial component of TRICAST's PBM oversight process. TRICAST reviews rejected Medicare Part D prescription transactions to ensure that plan management is aligned with appropriate plan design adherence. Their trained staff analyzes rejected prescription transactions to ensure that the six protected classes (Antidepressants, Antipsychotics, Anticonvulsants, Antiretroviral, Immunosuppressants, Anticancer) are not affected. TRICAST also analyzes and reports on rejected claims during a plan enrollee's transition period.
After a rejection analysis, TRICAST is able to determine if the majority of drugs were -- or were not -- covered. They also load and display all secondary messaging sent to the pharmacy provider to further support the oversight process.
TRICAST provides their analysis in reports that contain pivot tables, analyzing the type of reject by pharmacy and its timeframe. These pivot tables not only provide a breakdown of reason codes and a summary of the count of rejects, they also allow for actionable results, review, and resolution.
Complete Transition Patient Analysis
TRICAST loads all relevant eligibility to provide a complete third-party Transition Patient analysis. Inclusion of Transaction Reply Reports (TRR), Monthly Membership Reports (MMR) and Medicare Advantage and Prescription Drug (MARx) files the system portrays any patient experiencing a change in plan design, group or enrollment as "Transition." These patients will then have a separate rejection analysis done to ensure oversight of transition compliance.
Including PDE and source claims on an ongoing basis enhances oversight and compliance through reporting of patient receipt of appropriate treatment post rejection. Compliance reporting supports the primary concern of patient treatment.
The TRICAST Solution
With so many alternatives to selecting Pharmacy Benefit program oversight auditors and consultants, how do you decide? The TRICAST team possesses a very unique combination of:
- Deep domain focus on the pharmacy benefit industry
- Highly developed software and tools tailored for PBM and program analysis that utilize 100% claim analysis
- Experienced consulting and auditing perspective
Our background, coupled with our mission to address your complicated program issues with clear and actionable information, makes TRICAST an excellent partner.
TRICAST, Inc. is a leading pharmacy data, analytics, and consulting firm founded in 1997. TRICAST has leveraged more than 25 years of technology and claims processing expertise, extensive client insight and a team of industry experts to offer forward-thinking, full-scope pharmacy benefit oversight solutions to our clients.
We provide audit services as the core of our business, and have assessed multiple types of pharmacy programs. Our broad experience across payors of widely differentiated size and type, combined with our focused experience in pharmacy, enables us to deliver a comprehensive assessment of pharmacy programs.
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SOURCE TRICAST, Inc.