Specialty Pharmacy Solution
Expanding Lab Insights to Specialty Pharmacy
Specialty Pharmacy Trends
- Hospitals and physician groups have incorporated specialty pharmacy into their business models with more than 90% of large hospitals providing specialty pharmacy services5
- Oncologists make a 6% mark-up on dispensing chemotherapy medication, and a growing number of medical specialties are following suit5
Managing specialty pharmacy claims through the medical benefit remains a challenge
of specialty pharmacy costs are paid under the medical benefit3
0
%
Billing errors and quality issues can impact the health and wallets of your members
Billing for medical specialty pharmacy is complicated and prone to a variety of billing errors and clinical quality issues that include:
- Unapproved off-label use
- Dosing and frequency-of-administration errors
- Overbilling of medication waste
- Age-inappropriate treatment
Post payment review is inefficient and leaves savings on the table for you and your members.
- A prepayment model is optimal, ensuring payment consistent with policy prior to payment being disbursed.
Avalon has adapted its proven automated policy enforcement lab claims editing system to apply a health plan’s medical specialty pharmacy clinical and administrative policies in real-time.
The Avalon Process
Health Plan Adjudicates Medical Claims
Avalon integrates with health plan claims systems – one integration supports both lab and specialty pharmacy solutions
Avalon Applies Policy-Based Edits to Claims
Lab and specialty pharmacy claims are passed to Avalon where proprietary edits are applied, enforcing plan policies (with real-time response)
Real-Time Response Informs Claim Payment
Reimbursement is appropriately adjusted for ineligible billed services generating cost avoidance for the health plan
Avalon Specialty Pharmacy Solutions
- Can help you identify the medical benefit claims appropriate for payment consistent with policy while preventing payment for unnecessary or wasteful drug administration
- Requires no incremental health plan IT support for current LBM clients
- Ensures payment consistent with the appropriate science and standards of care that align with your member’s benefits
- BenefitsPRO. August 13, 2021. Scott Woolridge. https://www.benefitspro.com/2021/08/13/specialty-drug-trend-moderated-in-2020-but-is-likely-to-regain-upward-momentum/
- https://www.biopharmadive.com/press-release/20210721-top-tech-predictions-for-the-future-of-speciality-pharmacy/
- CVS Health 2018 Drug Trend Report. https://payorsolutions.cvshealth.com/insights/2018-drug-trend-report
- https://www.cbo.gov/publication/57126
- https://www.ajmc.com/view/unraveling-the-growing-influence-of-consolidation-340b-and-industry-in-specialty-pharmacy