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‘Tis ALWAYS the season….for rejected claims analysis.

By December 17, 2019CMS, PBM

As year-end approaches, most plans are conducting claims testing to ensure that formularies and benefits are administered correctly on January 1 and beyond.  Plans and PBMs alike that have experienced audit findings are implementing systemic changes to prevent further exposure in future audits.  Daily denied claim review is no longer a best practice but an industry norm.

In 2019, there were some trends in findings in the Formulary Administration portion of the Program Audits.  Plans should be sure that they are incorporating review of the following areas in their year-end and on-going test plans.

Protected Class Products

For new beneficiaries, Sponsor failed to afford an initial fill of a protected class product with a prior authorization or step therapy for new starts (Type 2) formulary requirement.

New Members in Transition

New members are failing to be identified as eligible for the purposes of transition. This could be due to bad plan eligibility loads, failure or delay in the PBM setting the beneficiary’s transition start date, or a combination of both

Prior Authorizations

Prior authorization setup issues continue to be targeted for CMS audits. CMS thoroughly reviews all effectuated prior authorizations to validate the authorization level is appropriate, is not more restrictive than the CMS formulary and/or plan benefit, and the authorization was entered timely and did not interrupt the beneficiary’s access to the medication.

BluePeak assists plans with year-end and year-round rejected claims monitoring.  BluePeak has a robust rejected and paid claim review system that assists plans in meeting the CMS expectation that plans monitor point-of-sale activity. The rejected claim review program also has customized analytics to focus on appropriateness of the rejection per the plan approved formulary and benefit.  Contact us today and we can help you build a customized claims testing program.