Deciding which pharmacy benefit manager to work with is a challenge. A lack of transparency, misaligned incentives and complex contracts can make it difficult to know if you’re making the best decision on your drug spend.
December 2024 | Get the latest from the best RBP advocates and auditors
PBMs: Are You Getting Good Advice? – Part 1
Unbundling health plans can be rewarding for both employers and their employees, but it's no secret that it comes with a unique set of challenges. Deciding which pharmacy benefit manager to work with is one of those challenges. A lack of transparency, misaligned incentives and complex contracts are just a few of the complexities that can make it difficult to know if you're making the best decision on your drug spend.
In this episode of ClaimTalk, experts Marc A. Sweeney, Pharm.D., BCMAS , Trevor Daer and Mike Kroupa examine the qualities that make a good PBM partner and how to recognize if your PBM is the right fit.
As a privately held, family-owned company, we are proud of the fact that we can do what is right for our customers and reinvest profits to help our company grow bigger, faster and stronger with each passing year. Our client retention was over 90% this past year. That is no small feat and a testament to the continued focus on value creation and a comprehensive solution as co-fiduciary for our client partners, their employees and families. Read more...
Audit Spotlight
Cynthia Swanson, RN, CPC, CEMC, CHC, CPMA
Senior Audit Manager
Egregious Charges, Price Transparency and Pricing Tools
In this month’s Audit Spotlight, we focus on a claim example where our audit team zoomed in closer on the billed services and related charges. We considered three questions:
Is the hospital really charging this much for services performed in the emergency room?
Is this an error in hospital billing?
Are the hospital charges egregious for the services provided and billed?
DirectAccess+™ clients and members achieve maximum protection and savings. To establish savings information, ClaimDOC analyzes commercial contract pricing from data disclosed by hospitals and health plans. The audit team performs line-by-line claim audits to help clients and members maximize their savings. Below is one recent audit result showcasing substantial savings.
Greenville, South Carolina
Three-day hospital stay for the treatment of spinal stenosis, spondylosis and related surgery
Disclaimer – The analysis of any medical billing or coding is dependent on numerous facts, regulations, payer policies and codes, as well as the controlling plan description. The information contained herein is intended to provide a real-life example of opportunities for savings through ClaimDOC services but is not intended to provide medical, legal, or financial advice.
Member Experience
Feedback From a Member
"Daisy is awesome! She is very pleasant on the phone. I want to thank Daisy for being professional and helpful. She made me laugh when I was aggravated with a bill from one of my providers."
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