Happy Anniversary, Claims Manager Plus: Two years of successfully closing the gap on hospital pharmacy billing claims
Running a hospital pharmacy is a complicated business, especially considering the prohibition on Medicaid duplicate discounts and the many varying requirements from payers that can wreak havoc on your bottom line. That’s why Sentry continually works to develop new tools and services to help you stay on top of things and keep your reimbursements moving.
Recently, Sentry marked the two-year anniversary of Claims Manager Plus, an automated software solution that helps hospitals adhere to payer requirements, minimize denials and speed up processing of any kind of claims by any payers, or for carving in or out 340B. It’s also indispensable in helping manage complex, government-mandated reporting requirements — including Medicaid duplicate discounts, one of the biggest compliance risks for covered entities.
Claims Manager Plus helps you correct errors on claims and adhere to other requirements by flagging items such as:
- Missing modifiers and prices
- Purchase validation of NDCs billed
- Unspecified destination payer codes
- Incorrect NDC codes
- NDCs not matched to HCPCS codes
- Crossover modifiers between payers
The tool automatically modifies claims based on the configurations you establish, including individual state Medicaid requirements. It flags errors and rejections and can re-validate them based on edits you make live in the application.
Best yet, CMP uses machine learning, so changes you make are incorporated into future claims, automatically adjusting the information with no need for manual intervention. These auto-corrections continually decrease the percentage of claims that get rejected as time goes on.
A boon to users
The ability to make edits directly in the platform was especially attractive to one pharmacy regulatory analyst who manages the 340B programs for 26 covered entities at a large health system. Before signing up with CMP, the analyst said she had to coordinate edits with central billing whenever there were mistakes and then resubmit the claims.
Now, Claims Manager Plus allows her to automatically convert different measurement units on dispensed drugs to comport with those recognized by the Medicaid program in the state where the health system is based. Previously, the analyst spent roughly half her time chasing down correct NDC codes with billing and trying to run them through electronically.
CMP, she said, “has saved us hundreds of thousands of dollars in man hours and allowed our staff to focus on additional priorities that benefit both the hospital and our 340B program. To have freed up so much of my time to work on compliance in the hospital has really been invaluable for us from a 340B standpoint.”
For a 340B program coordinator at a different health system, CMP was a huge help in meeting the state’s Medicaid program rules.
Previously, the program coordinator had been overwhelmed by the demands of matching miscellaneous HCPCS codes for processing Medicare and Medicaid claims to NDC codes for 340B reporting, plus the state’s requirement to add a modifier to 340B claims to remove them from manufacturers’ Medicaid rebate invoices.
Manually auditing so many claims “consumed my days, and some nights,” she recalled.
Claims Manager Plus automated those processes and allowed her to directly edit NDC codes, modifiers and prices on demand in the application, which would then incorporate those changes into the rules engine so they didn’t have to be repeated. CMP also compared specific NDCs to invoices to ensure a match or find the correct NDC. Those claims that couldn’t be matched to an NDC are dropped into an edit file for manual review.
“Today, I probably have to edit fewer than a dozen clients per site, per day,” she said. “And it takes me no time at all to go through, which is great, where I was spending all day editing claims before.”
The program coordinator said the biggest benefits are the confidence in knowing that claims are being handled properly and the time savings it has provided her.
“It’s a godsend to me, and I am grateful for it every single day,” she said.