PHARMACY CONTRACT ANALYSIS

Every mariner knows the importance of exact calculations when charting a course to sail. Even being just a few degrees off the mark can result in missing the desired destination by many miles and remaining adrift in dangerous open waters.

In kind, a company requires the expertise necessary to arrive where they intend to be. Medliance uses its broad knowledge gathered from years of pharmacy experience to determine where its clients headings are set and determine if that will deliver them where they want to arrive. Once we know where they are we can determine where they need to be and chart a course to optimize their pharmacy agreements.

Whether Fee for Service or Per Diem it is important to know where the danger points are and plot a course to avoid them. Medliance inspects hundreds of agreements and knows what pharmacies are capable of providing. Medliance will analyze your current agreement and map it against the options and opportunities that will quickly optimize your pharmacy cost. Using Medliance consulting services can deliver the most cost and service effective agreements and insure a healthy financial relationship with your pharmacy.

INVOICE OVER PAYMENT RECOVERY

Once a journey has begun it is critical that new readings and adjustments are continual, made to ensure a safe passage. Medliance provides a Continuous Improvement Process framework that does just this. Together we will: review course, check measurement, report progress and implement corrections to ensure that over a period of time all processes and outcomes are continually improving.

To track the progress we are making to our desired location we must check where we have already been to know if we are on the correct track. The first measure in our journey is to check the previous invoice’s accuracy.

Medliance will assist you in recovering overpayments that may have been made to the pharmacy. A measurement check or audit is performed on previously invoiced pharmacy products and services, which identifies overpayments made to the pharmacy.

These audits identify not only current invoicing issues, but also any points of improvement that need to be made going forward. They also establish a standard for billing and dispensing practices prior to the implementation of Medliance’s cost saving systems.

This important step reduces costs by identifying overpayments and filing for return of these overpayments; and optimizing the future cost confinement practices to be implemented.

MEDICATION DISPENSING COST CONTROLS

Dispensing medications has become far more complex than giving lemons to sailors with scurvy or bleeding out bad tumors. Today it is difficult to manage with adroit skill the many facets of medication management while maintaining the lowest cost.

Real time adjudication is vital because it allows for cost saving filters to be enacted immediately to improve the use of controls that can maintain high levels of care and at the same time directly reduce the cost of pharmacy service.

There are many filters available to assist with dispensing controls including:

Dosage control	Time limits	Preferred Manufacturer
Coordination of Benefits	Census Controls
Dietary Protocols	Generic Mandates	High cost meds Control
House Stock Mandates	Prior Authorizations	Quantity Limits
Duplicate Therapy	Contract elements control

 

IV ADJUDICATION AND AUDIT

The most uncharted risks for Long Term Care pharmacy cost is the IV billing. Typically the nursing staff has limited experience with the issues of pricing an IV correctly. The complexity of pricing and cost controlling filter adjudication increases when the process moves from fixed oral medications to infusion or IV adjudication.

IVs adjudication has to take in to account included (non-billable) items like supplies, diluents, tubing, ect. and be able to price by predominant med or per diem pricing matrixes. Question to ask are “Were the meds billed using unit pricing or metric quantity pricing?” A pharmacy using an inappropriate billing unit can increase a billing by 300% higher than the appropriate rate. If infusion billing is contracted as per diem rates; are the invoices reflecting the actual patient days or does it include the excess product shipped? This also can increase a residents cost of meds by several multiples if not identified and corrected.

The process and method used by Medliance is able to capture repetitive billings on a single dose billing from multi dose vials. Basically what this does is restrict the use of higher cost products in order to insure that the facility is using the most cost effective ingredients for IVs.

Then there are disparities in pharmacy systems that may be limited in delivering the claim to be verified. This raises the complexity for the pharmacy to bill it correctly. A much higher percentage of billing errors happen in IV pricing than any other portion of a facilities billing.

Medliance has addressed these issues by implementing three separate IV adjudication processes. Also a second periodic manual review by our IV management team can indentify practices in the pharmacy that can lead to billing errors. Medliance’s implementation team works with your pharmacy to determine the right approach for your situation.

CONSULTING AND AUDIT

Often in the days of the grand sailing ships captains would stop at ports and hire area pilots to take them safely into waters that they were not familiar with. Sometimes it was to have an area expert that knew where the underwater barriers were and other times it was to get a certificate of passage. A note vouching for a ship as friendly to the country whose flag it was traveling under. This would prevent unexpected capture and attack.

Medliance is often the pilot that brings order and safety to operator’s pharmacy relationships. Medliance uses its consulting pharmacists and experienced technicians that have been specifically trained in the billing aspects of pharmacy to monitor and manage the pharmacy process. Consultants are available to assist with navigating through contract negotiations, protocol selection, staff in-services, billing audits, workgroup participation, etc. Consultants report weekly to our senior management team regarding the status of all consulting engagements. Our VP of Client Services routinely follows up with clients to ensure satisfaction with the consulting services.

CONTRACT NEGOTIATION

After Medliance has identified the applicable course adjustments specific to your existing agreements we begin to negotiate the necessary improvements to move the contract to its ideal state.

Medliance will establish a contractual relationship that will allow the pharmacy and facility to strategically work together to meet the resident needs, while minimizing the operational stress that mis-aligned understandings can create.

Working from our history of established optimal agreements, the work will commence for the negotiation of an improved agreement. Medliance’s negotiators establish pricing and dispensing service level agreements in the contract for every medicine. These negotiations entail everything from pricing agreements and structures to pharmacy’s ability to deliver the services necessary to smoothly operate your homes.

These improved terms result in significant price savings and improved dispensing practices that create lower costs to the facility and an easier work environment for your staff.

PRICE ASSURANCE ADJUDICATION

From ancient times through today there has been continuous improvement in sailing technology. From the slave powered rowing Dragon Ships of the Vikings in the 11th Century to the nuclear powered aircraft carriers of today; improvement has made the ability to defend one’s treasure easier and less costly. The power and the reach of one ship today would have required hundreds or even thousands of ships centuries ago.

Yes, an important aspect of Medliance’s success is its innovation. Medliance was the first to bring real-time electronic adjudication to the Long Term Care market. This did away with manual monthly bill reviews that often missed the level of detail and accuracy that is possible today. It allowed for the first time accurate pricing of each and every pharmacy claim at the moment of dispensing. This saves our clients many hours of haggling with their pharmacy provider over what should have and should not have been billed. The adjudication controls the price, quantity, preferred dispense method and many other controls that has reduced the cost of meds and created a competitive advantage over our client’s competition.

MANAGED CARE REVENUE RECOVERY

Often utilizing Managed care agreements can be like sailing through a fog. It can be unclear to the billers what is included in your per diem rate, what is excluded all together, and what must be billed as a contract pass through billable exclusion; on top of this, when are prior authorizations required in order to be paid at all!

Medliance Managed Care services assist the facility in identifying all orders that can receive revenue reimbursement from your managed care partners. The system can also automatically create timely action reports that can notify any assigned resource when Prior Authorizations approvals are required.

An unbilled managed care charge is a 100% loss of revenue. The money is yours if you know it is there and lost if you don’t. Medliance can identify each and every claim to be submitted for payment. Unidentified Managed Care claims can mean tens of thousands of lost dollars a year for a single facility.

PHARMACY INVOICE RECONCILIATION

Being off your charted path by as little as two degrees will deliver you to a different place than you intended to arrive at. The ships pilot checks and rechecks the accuracy of their charts and logs. In the same fashion Medliance checks pharmacy claims in real time for accuracy before it is delivered to the facility. Medliance has also created a second set of checks and balances to assure billing accuracy; it is the Medliance Electronic Invoice Reconciliation. Dual verification of claims insures that the adjudicated claim is actually what is delivered on your invoice. This allows for a new level of pharmacy invoice transparency to be created for every Pharmacy Invoice.

No longer do facilities need to write checks for their resident’s medications in blind faith that the pharmacy bill is accurate. Medliance systematically reviews each line on the pharmacy invoice to help ensure all applicable orders are subjected to the contractual price and dispensing controls maintained in Medliance’s online claims system. Any billing anomalies are reported to the pharmacy to take appropriate action to correct.

Are your residents billed under the correct facility? Are your orders getting billed in a timely manner? Are your pharmacies choosing the most appropriate NDC? Are you getting billed for products or quantities that are not within the contractual limitations because the pharmacy didn’t send the claim through the online cost and dispensing controls? Are you receiving the credits the pharmacy has agreed to? These are only some of the questions the Pharmacy Invoice Reconciliation process answers for for you every month. Each line on the pharmacy bill is identified and categorized to make the approval, correction and rebilling process more efficient. This additional review offers inherent billing transparency, and instills the facility with greater confidence that their residents’ medications are more accurately billed, and peace of mind that payment can be authorized.

MEASUREMENT AND REPORTING

We have all seen beautiful pictures of light houses that protected ships from grounding on the rocks, but few of us remember what were known as the “low lights”. A sailing ship would be able to safely enter a harbor at night without crashing on the harbor walls by lining up a lighthouse up on the hill with the lowlights on the beach of the harbor. This would create a straight line to the opening of the harbor and allow the ship to sail straight into the harbor and miss the unseen dangers.

The purpose of using all of the many tools that Medliance provides is to bring your pharmacy billing, resident care and pharmacy relationships in to a safe harbor. You can know that your billing is accurate; the meds are the right meds to deliver high resident care and lower cost to your facility. You are reducing the month end and daily labor of your staff and increasing the ability to manage your pharmacy cost and billing accuracy.

The daily adjudication and the extensive work completed by the Medliance staff is much like the light house up on the hill with high visibility.

However, Medliance also delivers daily, weekly and monthly action and measurement reports to communicate and navigate the unseen risks that happen each time a resident requires medications. These reports are the low lights that ensure a safe arrival for resident care and facility profitability. Action reports are small and easy to read management reports that help guide and direct the affairs of your pharmacy management. Action reports reflect the small adjustments that need to be communicated and acted upon to secure all of the saving you desire.