The U.S. pharmaceutical industry shows no sign of slowing down: In 2020, 6.3 billion prescription medications were dispensed1 – up from 4.2 billion in 2019.2 While this growth certainly has the potential to increase revenue for manufacturers, it also presents a huge challenge when it comes to managing the amount of prescription utilization data associated with this level of volume. What’s more, payers often provide inconsistent rebate claims data that is typically erroneous and formatted uniquely. Mistakes are easy to make in this situation and can add up to as much as tens of millions of dollars in revenue loss.
Additional challenges such as the shift to more complex medicines, intensifying pricing pressures, and the constant threat of regulatory changes make it very difficult for pharma manufacturers to ensure contract and regulatory compliance and grow profitably.
Model N Validata is an automated solution that utilizes script-level validation tools to monitor, investigate, and identify suspect claims data in a timely and efficient manner to help overcome these challenges in commercial programs as well as the Medicaid Drug Rebate Program. Read on to learn how.
Commercial programs: Ensuring accuracy in prescription management
Bigger volumes, higher pricing, deeper discounts, and increased contract complexity combine to produce a greater chance of receiving inaccurate or incomplete utilization data from commercial payers. This is especially true for physician-administered drugs, which flow through different payment cycles within the market before entering into manufacturer contracts. Given these circumstances, intense scrutiny of incoming data is required.
Validata allows users to flexibly manage varying inbound prescription-level data formats and define which validations to run automatically post-import. Accurate utilization information is published downstream for rebate processing, error reporting, and industry-standard reconciliation file generation, ensuring claims are paid properly and in a timely manner.
Medicaid Drug Rebate Program: Avoiding duplicates, contract noncompliance, and other issues
Maintaining compliance with Medicaid calculation and reporting requirements is essential for pharma manufacturers. Slight errors in calculations or unnoticed duplicate prescriptions – which are common when a beneficiary has multiple coverage options – can cause millions of dollars in overpayments or result in costly overcharge penalties.
Validata brings in Medicaid script-level data with flexible data formats to better flag those claims eligible for benefit coordination and those that should be flagged as invalid payments. Rules automate validations for average rebates per unit and total reimbursement amounts to assess exposure and manage costs. With this enhanced capability, manufacturers can avoid paying duplicate or ineligible submissions, as well as provide necessary supporting information for resolution of Medicaid rebates payment disputes.
Standards matter: National Council for Prescription Drug Programs (NCPDP)
Read our next blog post highlighting the value of Model N Validata, where we explore its ability to keep pace with ever-evolving NCPDP standards.
Reference Articles:
1“The Use of Medicines in the U.S.” IQVIA Institute. May 2021.
2Matej Mikulic. “Total number of medical prescriptions dispensed in the U.S. from 2009 to 2019.” Statista. August 2020.
