Managed Care/ PBM
Assessment of HIPAA Processes and Procedures to Protect PHI
| Industry | Managed Care/ PBM |
| Problem | PHSI’s client was evaluating its HIPAA compliance throughout the organization as it relates to privacy and security. However, the client understood the need to reinforce with employees what PHI can and cannot leave the organization and review the operational and technical safeguards in place when PHI leaves the organization. |
| PHSL Solution | Conduct a focused assessment to identify and document the following: • Business reason for sending PHI • Type of file/report/document • Frequency (scheduled and/or ad hoc) • Systems generating PHI • Location of PHI on the client’s systems • Method for distribution (email, SFTP, etc.) • Process to validate PHI is delivered to the intended recipient |
| Results | PHSI prepared a twenty-question interview to review the client’s internal processes and procedures to help PHSI and the client identify potential HIPAA related issues. PHSI conducted interviews to gain the perspectives of the client’s staff, focusing on different roles and various areas of responsibility. The staff members were part of the teams that were identified as potentially sharing or distributing PHI to outside parties. The selected interviewees used different systems within the client’s organization and had different business needs for sharing data containing PHI with their business partners. PHSI compiled all the interviewee’s responses and provided the feedback to the organization’s Privacy Officer. The survey results were used to reinforce HIPAA compliance and improve process and procedures to protect PHI. |
PBM Contract Variance Analysis
| Industry | Managed Care/ PBM |
| Problem | A PBM requested an independent investigation of a pharmacy network contract with a retail pharmacy chain. The contract required an in-depth review to assess a disputed variance between the paid claim rates and the contracted rates and the PBM’s total payments to the pharmacy. |
| PHSL Solution | PHSI examined the pharmacy network contract details to identify the agreed upon Generic Effective Rates (GER) and Brand Effective Rates (BER). PHSI applied the contracted rates to the processed claims over the contract life. A comprehensive analysis was performed and a sum of the price difference between the paid claims and contracted rates was summarized on a quarterly basis. |
| Results | The PBM client obtained an independent perspective of the contract terms and reprocessing of the claims history to calculate the GER and BER per the pharmacy network contract. The PBM better understood the factors and variations that contributed to the disputed rate with the contracted pharmacy chain. PHSI's independent analysis was used as a basis for resolving the dispute. |
Increasing Efficiency of Newly Hired PBM Analysts
| Industry | Managed Care/ PBM |
| Problem | PHSI was approached by a PBM with a need to improve the consistency of their data analytics for pharmacy networks and clients. The PBM was experiencing analytic inconsistencies with current analysts and difficulties training their new analysts on how to properly perform data analytics and reporting. |
| PHSL Solution | PHSI collaborated with the PBM to create a training program for data analytics as well as listed several talking points that would be useful for the client while training their new analysts. PHSI provided both a live session of the webinar training that was recorded for the client to use in the future. |
| Results | By creating and recording the webinar training, PHSI was able to provide the client with improved efficiency by educating new analysts in a consistent manner to enable efficient and effective data analytics and reporting. |
Specialty Drug Reimbursement by Pharmacy Type
| Industry | Managed Care/ PBM |
| Problem | PHSI was asked to investigate specialty drug reimbursement by pharmacy type for a health plan. The client was focused on comparing their specialty pharmacy to the PBM’s specialty pharmacy and all other retail pharmacies. The client was beginning the RFP process for PBM services and wanted to examine the margins its PBM was making on their specialty prescriptions. |
| PHSL Solution | PHSI utilized the health plan’s specialty drug claims data to generate several data views by pharmacy type, single source drug, multi-source drug , drug specific examples and segmented outliers. PHSI provided profit estimates for the PBM specialty pharmacy. |
| Results | There was no single pharmacy type that consistently offered the lowest costs for specialty drugs. The lowest cost option was drug dependent. However, there were many drugs where the differences were negligible, and there were no clear winners. PHSI was able to demonstrate the client’s PBM was making a healthy margin on specialty prescriptions. With this information the client was in a better position for the upcoming RFP and negotiation process. |
Maximizing Profit Potential for PBM
| Industry | Managed Care/ PBM |
| Problem | The client provides a supplemental PBM program for patients to lower their out of pocket costs. The client wanted to improve generic purchasing via different wholesalers to lower their cost of goods. They also wished to review their current medication list in order to identify both savings opportunities and areas for improved inventory management. |
| PHSL Solution | PHSI completed a detailed analysis of wholesaler prices on the identified drug products using client provided information. PHSI also reviewed the pharmacy’s drug list and inventory. By readjusting minimum and maximum quantities of medications available to be ordered, both on hand inventory and out-of-stock situations improved. This minimized the on-hand quantity of stagnant products while increasing the average inventory turns per year. |
| Results | Utilizing the pricing analysis provided by PHSI, the client was able to optimize their purchasing efficiency when negotiating with wholesalers. The client also saw an increase in inventory turnover reflecting a growth in business performance. PHSI continues this service on an annual basis to further reduce costs allowing for both expansions in sales and financial profit. |
Management of MAC List for PBM’s Major Retail Pharmacy Contracts
| Industry | Managed Care/ PBM |
| Problem | A PBM client was contracted with various national pharmacy retailers. Included in these contracts were guaranteed Generic Effective Rates (GER) established by the different parties. Appropriate MAC lists were needed to adhere to the agreed upon GER rates for each pharmacy chain. |
| PHSL Solution | PHSI utilized monthly claims data and current AWP pricing to manage the MAC list for the PBM. Based on utilization data or market place changes, PHSI was able to adjust the MAC list accordingly while meeting the contracted GER. |
| Results | Routine management of the MAC list allowed the PBM to follow through on the GER guarantees. PHSI was able to address any possible deviations early in the year rather than during an annual review. The client maintained beneficial relationships with the retail chains and prevented financial penalties. PHSI continues to monitor market pricing and utilization data to update the MAC lists to continue meeting these GERs. |
Process and Claims Audit
| Industry | Managed Care/ PBM |
| Problem | The PBM was preparing for an upcoming audit from an important client that was looking to validate that the PBM is compliant with the terms and performance guarantees specified in the client agreement. The PBM requested that PHSI conduct a pre-audit of the client's agreement to prepare the PBM for the upcoming audit. |
| PHSL Solution | PHSI examined a year's worth of data to conduct a claims audit, reviewed the terms of the agreement including performance guarantees, and conducted interviews with PBM management to prepare the PBM for the client’s auditors. As part of the process and claims audit, PHSI analyzed the PBM’s process and procedures and made recommendations for operational improvements. |
| Results | The PBM was well prepared for the client audit and passed the review with outstanding results. The project provided a risk mitigation strategy by equipping the PBM with the knowledge to successfully navigate the client’s audit while improving its operational processes. |
Organizational Turnaround
| Industry | Managed Care/ PBM |
| Problem | The PBM's prior authorization process needed to be rebuilt due to the increased volume of requests. The existing process was inefficient, causing delays that resulted in service issues with their clients. The organization requested an operational assessment to streamline the processes allowing the business to handle future growth and complexity of prior authorization decision criteria while minimizing the addition of new staff. |
| PHSL Solution | The PBM’s prior authorization process required an operational turn around. PHSI investigated the root cause of the operational problems focusing on people, process and technology areas. PHSI used cost accounting techniques to benchmark operational processes and identify true cost of processing prior authorization requests. PHSI recommended an organizational restructuring, process improvements, and technology enhancements that increased operational capacity and throughput. Management controls were established to manage workflow, focus efforts on lowering costs and improving quality. |
| Results | The clients operations were stabilized and improved results were achieved as new management was hired to manage the prior authorization process. The implemented changes improved the work flow and enabled the PBM to operate more efficiently. |
Merger and Acquisition Due Diligence
| Industry | Managed Care/ PBM |
| Problem | The client was interested in acquiring a PBM and required an independent assessment of the performance of the target's pharmacy network agreements and assistance with predicting the drug spend and mix over the next three years. The client also needed a synergies analysis with their existing contracts. |
| PHSL Solution | PHSI analyzed six months worth of claims data and summarized the information by pharmacy chain. PHSI provided a confidential way to provide a risk assessment and potential benefits of a combined entity. |
| Results | PHSI's independent analysis and risk assessment enabled the client to obtain an outside perspective for the financial opportunities of an acquisition. This information assisted the client in determining how aggressive they wanted to be when bidding on the PBM. |
PHSI Creates Pharmacy Chain MAC to Meet PBM Contract GER Guarantee
| Industry | Managed Care/ PBM |
| Problem | A PBM contracted with a national pharmacy chain for a MAC list with a specific Generic Effective Rate (GER) guarantee. The PBM’s current MAC list did not achieve the contracted GER rate. |
| PHSL Solution | To meet the GER guarantee, PHSI utilized pharmacy claims data to create a MAC list specific for that pharmacy chain that met the contracted GER rate. |
| Results | PHSI was able to provide the PBM the information that would ensure the GER for the contracted retail chains, meeting the contractual agreement with the pharmacy chain. PHSI continues to update the MAC lists to continue to meet these guarantees based on market pricing and utilization changes. |
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968 Perry Highway
Pittsburgh, PA 15237
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Phone: (412) 635-4650
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