Evaluating Payer Impact on Utilization with Claims and Coverage Data
To fully understand how payers impact patient access, pharma companies should be evaluating payers using multiple datasets, including both coverage/restriction data and claims data. While payer policies indicate how payers plan to manage a product or service, medical and pharmacy claims reveal how payers actually manage that product in reality. Taken together, claims and coverage […]
Coding Chaos: How Pharma Can Help Providers Get Paid
For manufacturers of medical benefit drugs, ensuring accurate provider reimbursement is essential. If providers are unaware of how to appropriately bill for a particular drug, their errors will result in claims denials, which in turn may lead them to stop prescribing that drug in favor of another. Inadvertent underbilling for services rendered is also a […]
Expanding Molecular Testing: What Payers and Manufacturers Should Know
Medicine has been trending towards personalization for decades. The growth of individualized medicine and new diagnostic technologies has resulted in drugs that are tailored towards patients’ profile and condition—and are much more effective as a result. These therapies rely on the existence of molecular tests, including genetic testing, predictive and prognostic biomarkers, and companion diagnostics. […]
How Much Does Medication Compliance Affect Site-of-Care Optimization?
In an effort to lower the cost of specialty drugs, many payers have initiated site-of-care optimization strategies. By encouraging patients to receive therapies in more cost-effective settings — such as physician offices, infusion clinics, or at home — payers can reduce unnecessary expenses while ensuring members receive clinically appropriate care. In addition to price concerns, […]
New HCPCS Codes for Generics: What Payers and Manufacturers Should Know to Ensure Accurate Reimbursement
As if medical billing and coding wasn’t challenging enough, 2023 brings a new layer of complexity: the establishment of unique HCPCS codes for generic drugs. Specifically, the new codes affect generics approved under the FDA’s 505(b)(2) new drug application (NDA) and biologics license application (BLA) pathways. In its Q3 2022 HCPCS Coding Cycle documentation, CMS […]
How Medical Billing and Coding Can Impact Patient Access
There are many moving parts when it comes to helping ensure that patients can get access to the therapies they need, but the role of medical billing and coding isn’t always top of mind. To be fair, medical billing seems to grow more complex by the day, and keeping abreast of the changes can be […]
Payers Are Using NDC Mandates, but Are They Doing Enough?
The drug development pipeline is dominated by specialty therapies, more and more of which are being managed under the medical benefit. Therefore, payers will increasingly need to manage those drugs themselves, given that the PBMs they’d normally rely on don’t process these sorts of claims. As a result, payers are looking to better manage medical […]
Navigating HCPCS Coding Changes to Prevent Medical Reimbursement Challenges
When it comes to medical reimbursement, there are several challenges that both payers and providers face in today’s rapidly changing regulatory environment. With new drugs and generics entering the market at breakneck speed and supply chain issues continuing to plague manufacturers, it can be difficult for stakeholders to keep up with the Healthcare Common Procedure […]