The effective monitoring and accurate reporting of key drug program metrics like drug spend, network utilization and third-party billing depends on numerous factors, but it begins with accurate bill coding. The ability of the payor – working cooperatively with their PBM – to determine when drugs have been inappropriately coded or charged during the billing process is therefore a vital aspect of any drug program evaluation.
Today, drugs are being prescribed and dispensed in widely varying settings by a broad range of practitioners – the result of which has been an increase in certain prescription drugs being incorporated into other charge categories. Primary examples KeyScripts has encountered include specialty drugs coded as DME, as well as surgical implants, procedures, injections and supplies billed using codes captured on pharmacy reports. In addition, when calculating network and out-of-network costs, physician-dispensed drugs may or may not be attributed as drug spend, as they can be included on standard medical billing forms, with their costs incorporated into other charges, ostensibly for reporting purposes. For these reasons, the standardization of the methodology by which drugs costs and network utilization – particularly for out-of-network charges – is critical in the reporting process, and therefore in determining the effectiveness of any workers’ compensation pharmacy program. Recognizing this trend, KeyScripts works closely with customers to examine and refine the basis for the items and billing codes included in their drug spend data, allowing the most accurate evaluation of their pharmacy programs – which should be a chief consideration for all workers’ compensation payors.
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