RC Claim Assist
Reduce Billing Errors for Medically Covered Drugs
- Ensure Accurate NDC to HCPCS/CPT® Code Mapping: Help providers use the correct National Drug Codes (NDCs) to align with HCPCS and CPT® codes, meeting payer requirements and improving claims accuracy.
- Convert NDC Codes to Units for Claims Processing: Easily convert NDC codes into billable units by supplying the appropriate HCPCS/CPT® code to support accurate billing and reimbursement.
- Reference AWP and WAC Drug Pricing Data: Access Average Wholesale Price (AWP) and Wholesale Acquisition Cost (WAC) for each HCPCS/CPT® code, with organized drug cards that simplify claim form completion.
- Improve Patient Access by Reducing Billing Errors: Minimize drug abandonment and access barriers by reducing billing issues and ensuring accurate reimbursement for medically covered therapies.
Reduce Billing Errors for Medically Covered Drugs
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How We Can Help
RC Claim Assist helps your team improve the accuracy and efficiency of reimbursement claims by providing tailored claim support and insights, reducing manual effort and claim denials, and helping ensure reimbursement codes and pricing information are applied correctly for better outcomes.
We help ensure accurate coding and reduce claim errors by providing tailored support that highlights the core value of correct NDC, HCPCS, and CPT® coding, guiding your team to apply codes correctly, minimize denials, and improve billing accuracy.
RC Claim Assist helps streamline claims processing and reimbursement workflows by providing targeted support and insights that clarify correct coding application (including NDC, HCPCS, and CPT®), reduce manual effort and errors, and enable smoother, more efficient reimbursement outcomes.
We help improve patient access by minimizing billing and reimbursement issues, reducing claim denials, and ensuring smoother, more timely reimbursement so patients can receive therapies without unnecessary delays.
Key Insights From MMIT
How Manufacturers Can Prepare for Impending Changes in PBM Incentives
This article was originally published in Pharmaceutical Executive on April 6, 2026.
Pharmacy benefit managers (PBMs) sit at the center of an increasingly complex web of relationships among manufacturers, health insurers, pharmacies and employers. While they streamline negotiations between employers and pharmaceutical companies, increase price competition and standardize claims, formulary and utilization practices, they’ve recently faced increased scrutiny because of potential conflicts of interest and opaque sources of revenue.
As a result, the Trump administration called on the secretary of labor in a 2025 executive order to “improve employer health plan fiduciary transparency into…compensation received by [PBMs].” With the passage of the 2026 Consolidated Appropriations Act (CAA), measures to increase PBM transparency became law. These restrictions represent a turning point for PBMs, but not in the way many pharma leaders might expect.
PBM Incentives Will Change After CCA Takes Effect
On its face, the act benefits employers and commercial health plans by prohibiting PBMs from retaining any portion of the rebates drugmakers pay. Once the law goes into effect on Aug. 3, 2028 (effective Jan. 1, 2029, for calendar-year health plans), PBMs must pass through 100% of rebates, fees, alternative discounts and other remuneration they receive to Employee Retirement Income Security Act-governed employer plans, further benefiting patients.
PBMs will also have to provide detailed reports on spread pricing practices, in which they charge employers more for a drug than they pay pharmacies, and incentives that encourage the use of PBM-affiliated pharmacy practices. By mandating that Medicare delink PBM compensation from list prices, the act may also provide a glimpse at future commercial reforms.
All these changes alter how PBMs are paid, thereby changing their incentives. Manufacturers will have to adapt in turn, shifting their approach to how they negotiate with entities such as Optum Rx and Express Scripts. However, contrary to how it might sound, the act won’t sideline PBMs; rather, it will force them to exert tighter controls.
Over the next two years, PBMs will intensify existing practices to reassert their leverage over market access. Pharma companies that fail to pivot will face unfavorable formulary placements, more competitive pressure and even exclusion.
PBMs Likely to Intensify Utilization Management
As rebate reforms constrain some of their revenue streams, PBMs will expand formulary placement and utilization management tactics to maintain an advantage in manufacturer access negotiations.
Barring excluding drugs from their formularies completely, PBMs will play more with tier placement, slotting some drugs within a class into higher tiers with higher copays to discourage their uptake. They may also widen the cost differential between tiers, narrow the number of drugs within a preferred tier or even completely restrict formulary access for certain indications for a multipurpose drug, making tier placement even more important in negotiations with manufacturers.
Even for two drugs on the same tier, PBMs can alter the frequency one is prescribed over the other by manipulating the conditions under which patients are authorized to take them. While these utilization tactics are nothing new, PBMs may intensify them in costly ways. For example, instead of requiring a patient to try drug A before drug C is covered — also known as step therapy — PBMs may now require a double step, mandating a patient try drugs A and B first, further discouraging the use of drug C.
More Stringent Prior Authorization, Rise in Flat Fees
Prior authorizations will also likely become more complicated, with PBMs going beyond physician attestation to authorize only patients with lab values that precisely align with a drug’s clinical trial inclusion criteria, rather than those within a wider acceptable range. Compiling these results will put added strain on physicians’ administrative teams, further disincentivizing them from prescribing certain drugs.
To sustain direct cash flow and fill the revenue gap created by rebate pass-throughs, PBMs might instead demand flat fees from drugmakers for formulary access. Flat fees may actually create more stable recurring revenue for PBMs, expanding their ability to impose additional management, data analytics and specialty management fees.
Finally, we’ll continue to see further vertical integration, in which overarching organizations consolidate PBMs, insurers and pharmacy networks under singular control. With PBMs even more tightly managing how drugs are covered and distributed, they can condition formulary access on dispensing through preferred or affiliated pharmacies, which will substantially affect manufacturers’ strategies.
Though the CAA diminishes some of their revenue channels, PBMs will still be able to strengthen their core levers of control to maintain their leverage. However, there are still many unsettled market access dynamics, potentially offering drugmakers new opportunities.
Outcomes-Based Contracting and Private-Label Manufacturing
As rebate-driven economics diminish and transparency for health plans increases, PBMs may lean more heavily on contracting strategies and private-label manufacturing.
Both PBMs and pharmaceutical companies have already been using portfolio contracting to establish the most favorable arrangements for formulary inclusion and profitability. Under heightened employer scrutiny, however, PBMs may ramp up strategies, including increasing cross-product concessions, negotiating entire classes or indications of drugs separately, and requiring more economic and utilization data from manufacturers to justify formulary inclusion to employers.
PBMs may also accelerate their shift to outcomes-based contracting from value-based arrangements. By tying manufacturer payments to real clinical results, outcomes-based contracting will further insulate PBMs from the risks of an underperforming drug and give them an additional avenue to increase revenue.
PBM private labeling will also shift power dynamics. In 2025, all three major PBMs launched their own biosimilars for Johnson & Johnson’s Stelara, following their success with Humira biosimilars. With more vertical integration, PBMs may expand their private-label pursuits to directly control more medications in their formularies. The question is, will the biosimilar manufacturing and management expenses be worth the potential gains? Historically, PBMs have preferred high-rebate, original medications over lower-cost biosimilars.
New Opportunities for Manufacturers
Although the extent to which PBMs will intensify these tactics is unclear, the following are three categories in which new openings exist for manufacturers:
- Single-asset advantages: If more transparency in negotiations increases the importance of proving the value of each asset to employers, smaller manufacturers competing on single assets may find new leverage against broad portfolio bundling.
- Benefits of scale: Large, diversified manufacturers could benefit from restructuring their entire portfolios to emphasize predictability and absorb profitability changes across therapeutic areas. Aggregating real-world data will also provide an advantage when establishing performance-based agreements.
- Emphasizing predictability: Drugmakers could potentially exploit PBMs’ preference for original medications by identifying therapeutic areas where PBM biosimilar strategies don’t make economic sense and leaning on drugs with more predictable rebates or clearer net pricing advantages.
What Manufacturers Can Do Now
For pharma companies, it’s important to realize that the 2026 reforms don’t dismantle PBM leverage; instead, they change the incentives that drive PBM strategic decision-making.
In response, manufacturers must eliminate outdated, rebate-focused approaches to pricing. They can immediately adjust their gross-to-net strategies for this more transparent environment, modeling how their products perform on net cost to employers.
They may also explore segmenting their strategies by channel, since the CAA affects Medicare differently from self-funded employer arrangements, for example. Finally, they can shift their portfolio strategies to emphasize predictability and negotiate across franchises, and undergird these agreements with real-world performance data to document the true value of each drug within larger bundles.
Though the new regulations won’t go into effect for another two years, drugmakers that act now to take advantage of the new opportunities they afford will maintain and even gain an edge in the current, PBM-friendly pharma landscape.
The Evolving Payer Landscape for Early Detection Tests
In many therapeutic areas, especially oncology, physicians have been using early screening tests for decades. Designed to identify the early signs of a disease or condition before any noticeable symptoms develop, early detection tests support timely medical intervention.
In the U.S. alone, early cancer screenings have been credited with preventing 4.75 million deaths (and counting) since 1975. According to the National Cancer Institute, the prevalence of cancer screenings have contributed significantly to a 34% drop in overall cancer mortality from 1991 to 2022.
Unfortunately, the majority of cancers still do not have a recommended screening test. These cancers are usually diagnosed in symptomatic patients, who typically present in later stages of the disease; experts estimate that these diagnoses account for 70% of cancer-related deaths.
New developments in blood-based molecular diagnostics, which use various molecular signals to detect early-stage cancers, are already here—but what about payer coverage?
To better understand how payers are currently managing access for early detection tests, the MMIT Oncology Index team conducted research with commercial payers representing 119 million covered lives. Let’s take a look at the data.
Early Detection Improves Outcomes—But Coverage Gaps Remain
Our research found that 21 of 30 surveyed payers currently cover early detection tests in one or more oncology therapeutic areas. Payers representing more than 63% of U.S. commercial lives provide coverage for colorectal, prostate, and breast cancer screening, which are three of the most routinely ordered tests.
While 45% of U.S. commercial lives are covered for lung cancer screenings, coverage for other early detection tests drops precipitously for less common cancers; for example, early screenings for kidney cancer are covered for only 12% of commercial lives. Interestingly, many payers seem unconvinced of the utility of these screening tests.
Payers who do not currently cover early detection tests indicate insufficient clinical evidence, lack of guideline support, and operational limitations as the primary barriers to offering coverage. As one health plan noted, “They are not part of the NCCN guidelines and effectiveness data is still lacking. We do not discourage members from getting such tests if they are willing to pay for them.”
Fortunately, all payers that currently cover early detection tests are interested in expanding that coverage, with lung, liver, and endometrial cancers most frequently earmarked for future inclusion.
So how do payers decide which early detection tests to cover? According to our research, payers consider clinical efficacy data, the population health impact, and cost effectiveness first and foremost when making coverage decisions. A test’s inclusion in national guidelines, as well as FDA approval, are also decisive factors for most payers.
FDA Approval Remains a Barrier for Multi-Cancer Early Detection Tests
Many oncologists are excited about the recent development of multi-cancer early detection (MCED) tests, which are capable of identifying dozens of early-stage cancers via blood-based liquid biopsies. MCEDs include GRAIL’s Galleri test, which was designated by the FDA as a Breakthrough Device in 2018 and is now in the final stages of Pre-Market Approval, and Abbott’s Cancerguard test.
While these MCEDs are not yet FDA approved or cleared, they are available now with a prescription, with most patients paying out-of-pocket. Payers show limited willingness to cover MCED tests prior to FDA approval. As one payer noted, “Without FDA approval, there is too much uncertainty around the clinical validity and clinical utility of these tests to support coverage. We would need clear evidence that the test accurately identifies cancer, meaningfully improves patient outcomes, and leads to appropriate management rather than unnecessary follow up testing or procedures.”
Once MCED tests receive FDA approval, nearly all payers anticipate offering coverage. The majority indicate a willingness to cover all approved tests rather than just certain ones. If MCED coverage is selective, payers expect to favor tests with stronger clinical performance, clearer utility, and better cost value.
Molecular Diagnostics and AI Expand the Screening Pipeline
Of course, MCEDs are not the only molecular tests in development. Several molecular early detection tests use a single blood draw to detect circulating tumor DNA, while others use methods like analyzing cell-free RNA for tissue-specific cancer signals, or deploying AI-driven molecular sensors to detect enzymes associated with certain tumors. With AI advancements, these tests can support more personalized treatment plans for patients.
According to our research, most payers are at least moderately aware that AI is being used to identify early signs of disease. In the future, payers expect AI-driven early detection tests in various therapeutic areas, most notably Alzheimer’s disease, oncology and neurological disorders. Payers anticipate that the use of AI-enabled tests will have significant impact on earlier diagnosis and treatment initiation, and will also improve diagnostic accuracy.
Early detection testing is entering a pivotal stage of innovation. Although new modalities and methods are in development, payer adoption of even the tried-and-true screenings is still highly variable. While traditional screening tests have established coverage pathways, newer modalities such as MCEDs, AI-enabled diagnostics and precision blood tests must still prove their clinical value (and their ultimate impact on patient outcomes).
For oncology manufacturers—especially those developing therapies for cancers that currently lack recommended screening tools—the rise of new testing innovations presents both a challenge and an opportunity. As new diagnostics expand the ability to identify cancers earlier, manufacturers should begin planning now for the ways in which earlier diagnosis might reshape patient pathways, treatment eligibility and market demand.
Manufacturers can strengthen their position by partnering with diagnostic innovators, supporting clinical evidence generation for underserved tumor types and demonstrating how earlier intervention can improve outcomes and reduce downstream costs. Just as importantly, companies should engage payers early to understand the evidence thresholds for coverage and reimbursement. For manufacturers focused on historically late-stage cancers, aligning treatment strategy with the future of early detection may become a critical competitive advantage.
Learn more about MMIT’s Oncology Index, which offers detailed analysis of payer management strategies and tracks coverage trends, site-of-care preferences, and relationship dynamics.
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