Managed Care Contracts and Incentives

Maximizing Managed Care and Medicare Revenue

Managed care and Medicare revenues are an increasingly important aspect of the pharmaceutical and biotechnology business, often constituting more than half of a manufacturer's sales. Yet, in a recent industry survey, more than 70% of responding manufacturers indicated they could be overpaying managed care rebates and fees, with overpayments accounting for up to 10% of their total managed care liability - a potentially severe source of revenue leakage. Moreover, the lack of accuracy and consistent, auditable processes can create significant compliance exposure.

Model N Managed Care: The First Integrated Industry Solution

Model N Managed Care addresses these issues by offering a comprehensive solution for administering the entire commercial Managed Care and Medicare Part D contract to claims to cash lifecycle. It provides powerful capabilities for setting up and maintaining contract deal structures and plan eligibility, managing the entire contract lifecycle, processing customer claims data, validating utilization submissions, and calculating and settling rebates, as well as managing adjustments and resubmissions, maintaining foundational data, and enforcing consistent controls over workflow, approval, and business reporting.

Model N Managed Care handles and automates all key incentive program elements, including qualifications, benefits, and payment details. On implementation of a contract, payments are automatically scheduled and tracking is initiated. Any subsequent contract changes or amendments automatically update the rebate programs as necessary - with no manual intervention required. Claim and utilization data from a variety of sources can be imported into the system, then validated and normalized. The application automatically applies the utilization data to the appropriate rebate payments, performs rebate calculation, and groups the rebate payments into payment packages for analysts to review. Notifications are also sent to appropriate approvers based on pre-defined business rules. If adjustments are needed after a payment has been made, e.g. to manage a back-bill, robust adjustment capabilities allow original payments to be backed out and reapplied against new payments.

Closed-Loop Support for Regulatory Compliance

The Model N Managed Care application is an integral part of the Model N Revenue Management Suite, giving users a comprehensive, user-friendly application incorporating industry best practices for managing incentive programs and claims processing. It is the industry's only highly flexible solution for managing commercial Managed Care and Medicare part D incentive programs that is architected on an integrated platform, as part of an application suite that manages different aspects of a manufacturer's business, including institutional and government business processes. This closed-loop approach integrates Model N Managed Care, Government Pricing, and FSS Compliance to enable out-of-the-box data sharing between the applications. In addition to sharing common master data, Government Pricing automatically receives and processes Managed Care rebate payments information, which mimimizes deployment costs and implementation or upgrade time. Price lists from Government Pricing and FSS Compliance are used during the contracting process to ensure net prices do not violate government pricing guidelines, which helps prevent negative financial repercussions, revenue leakage, and regulatory compliance risk.

Managed Care at a Glance