Payer Reject Rate for Drug Drastically Reduced After PHSL Analysis

IndustryPharmaceutical Manufacturer
ProblemA client offers a product that only needs to be dispensed once per year. Pharmacies dispensing the product were experiencing almost a 90% claim rejection rate from payers. The client wanted to understand the underlying reason PBMs were rejecting claims for their product.
PHSI SolutionPHSL was able to develop and complete a claims analysis process that sought the root of the issue. In the analysis, reasons for why certain PBMs rejected the claims were identified.
ResultsThrough the analysis, PHSL was able to pinpoint the underlying reason for the claim rejections, which revolved around the values that pharmacies were entering on claims for the days’ supply for the product. PHSL’s analysis provided the client with valuable learnings, which they used in their discussions with the affected payers. Once those payers understood the issue and implemented changes to their processing, the client began to realize a reduction in the claim rejection rate for their product that went from 90% to almost 40%.