Payer Reject Rate for Drug Drastically Reduced After PHSL Analysis
| Industry | Pharmaceutical Manufacturer |
| Problem | A 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 Solution | PHSL 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. |
| Results | Through 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%. |
Poll Results
August 2023 Question of the Month
What steps do you take when learning about an electronic prescribing challenge?
Root cause analysis: 0%
Compendia review: 0%
Engage a partner: 0%
All of the above: 50%
None of the above: 50%
July 2023 Question of the Month
Does your organization have a strategy for Humira biosimilar launches?
Yes, well defined: 0%
We have a framework: 50%
Waiting for clarity: 0%
No: 0%
Unaware of need: 50%
June 2023 Question of the Month
How far in advance of NDA/BLA expected approval do (or should) manufacturers begin planning their compendia submission strategy?
During Phase II Trials: 0%
Initiation of Phase III Trials: 66%
6 months prior to approval: 33%
3 months prior to approval: 0%
At time of approval: 0%
After approval: 0%
No strategy: 0%
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