Payers attempt to mitigate medical benefit submissions

With Injectable Claims, the root problem in the submission process is that payers cannot read NDC numbers on CMS 1500 forms, and there is no process in place to require providers to include such a data element. Remember, this is only true on claims submitted to a medical benefit, since pharmacy-adjudicated claims use NDC codes, not J codes.

There are three major ways that payers are attempting to improve the claims-payment process for injectable claims submitted to the medical benefit:

While each approach appears to be relatively straightforward, they all have associated benefits and challenges.

Risks associated with such an approach include loss of drug coverage for those members with a pharmacy carve-out and incomplete implementation of such a management initiative as a result of the large volume of provider-administrated injectables.

Some payers have required providers who submit injectable claims on a CMS 1500 to include an NDC number as well. This requires major education of the provider panel, a compliance measurement and correction processes, and IT infrastructure capable of reading and analyzing such information. There is significant variability in the compliance of such a program by geographical region and provider specialty type. We have found that oncologists commonly include NDC codes on their claims, whereas urologists and other specialists almost never do. Typically, this is a strategy used by payers who have exceptional provider service capabilities, a strong relationship with their provider panel, and who serve members in a relatively small service area.

Finally, payers are investigating the use of repricing tools, or are exploring the possibility of partnering with a vendor who provides such a service. There are a multitude of challenges associated with this approach.

From a development standpoint, the cost for a health plan to build such a tool may be as much as $1 million, and other IT projects compete heavily with this. Also, payers are still required to place NDC numbers onto each submitted claim, such that the internal or external tool can perform a comparison and submission correction.

Finally, the benefit management becomes very challenging, because as claims are changed with respect to their amount of reimbursement, different amounts are subtracted from the member's deductibles, and such "accumulators" must be carefully adjusted in parallel.