How To Stay On Top Of Payer Contracting And Drug Pricing?
The
contracts between insurance payers and pharmaceutical manufacturers are here to
stay in the medical world. In the last few years, these value-based contracts
have been growing. Not only that, these are bringing in higher payment rates in
the process of improving the outcome for the patients. They are also
supplanting the traditional contracts in which rebates on the payments were
based on volume and the formulary.
What Is Payer Contracting
& Drug Pricing?
Theoretically,
the 'at-risk' or value-based agreements are developed for positive development.
The pharmaceutical companies in such a scenario uphold the performance of the
drugs with these contracts. The process allows the medical facilities to offer
the best service and results to the patients.
However,
the reality has been a bit different. These contracts have been based on un-advanced
volumetric math, making them a value-based idea but not fully functional. It is
because manufacturers are still working on achieving a simple volumetric
percentage. Its efficacy is still based on the profit goals and payment within
these agreements.
In
reality, the improvement of value-based contracts can only happen when the
evaluation is based on more complex factors like lifestyle measurement and its
corresponding evidence.
For
instance, the outcomes can be measured based on the rate of HCV cure,
readmission to hospitals, and A1C counts on diabetes. The process also needs to
involve a care team and the lifestyle outcome to showcase the value-based
contracts, though it is not easy.
An
article published in Wall Street Journal mentioned that manufacturers and
insurers find immense complexity in tracking a patient's health. Mainly when it
is under the insurer, it poses to be a barrier. Also, with most contract
suppliers tied to the payment of prescription volume, the value-based contract
process becomes challenging. It also mentions that its setup can be perplexing
because understanding its success can be challenging to track.
For
instance, heart attack reduction based on drugs or decreased deaths because of
cholesterol can take ages, to be precise. Additionally, patients often change
the insurers; their jobs make it difficult to track them over time.
How To Stay At Top?
When
it comes to speciality healthcare - staying at the top of the payer contracting
and drug pricing is essential, even when the value-based agreements offer a
limited scope. In addition, since most speciality healthcare has used
cutting-edge pharmaceutical and other therapies at the high end of the cost
spectrum, maintaining revenue cycle management (RCM) is essential.
In
such a scenario, the provider and the payer want to ensure that the patient has
access to the treatment without getting embroiled in the challenges that plague
the value-based agreements.
As
part of the innovation and incorporation of the latest technology, the
healthcare system has been changing at a rapid pace. More than ever, it has
become essential to monitor spending. Hence the payers change the reimbursement
rates for the drugs frequently. For instance, the Centres for Medicare and Medicaid
Services (CMS) update their drug reimbursement rate every quarter for
Medicare. Unfortunately, it results in many payers of the nation following the
same schedule, thus leaving the providers of speciality healthcare to scramble
for constant adjustments.
It
needs to be taken into account that even a tiny adjustment in the rate of a
high-cost drug can cause a predicament to the financial health of a practice.
Therefore, the providers must maintain comprehensive visibility into the
contract of the payers, their payment rates, and the population of the patients
all the time.
One
of the critical steps in staying on top of the payer contracting is to have an
RCM solution with features that are highly capable of contract management. It
should be able to differentiate a flexible reporting system and take the
necessary steps to manage the contract of the payers while updating the drug
pricing. Given the expectation in the healthcare system today with high service
volume, it is vital to leverage the best RCM system to streamline the work
process and improve productivity by reducing the burden on the administrative
staff. It should also be able to offer flexible adjustments to different
financial projections, support compliance reporting, and be a sustainable
solution in the frequently changing medical environment.
How To Ensure You Are
Doing It Right?
These
are the solution to stay on top of the much-complicated payer contracting and
drug pricing issues. But we know following these could be pretty challenging.
In such a case, contact the 24/7 Medical Billing Services with the best RCM
software and a dedicated, experienced
team in medical billing and coding to ensure that your revenue
management is on the top. Then, based on the speciality care and the facility's
requirement, we will develop the RCM that can offer the best results for your
practice while ensuring you can scale better with improved ROI.
About
24/7 Medical Billing Services:
We
are a medical billing company that offers ‘24/7
Medical Billing Services’ and support physicians, hospitals, medical
institutions and group practices with our end to end medical billing solutions.
We help you earn more revenue with our quick and affordable services. Our
customized Revenue Cycle Management (RCM) solutions allow physicians to attract
additional revenue and reduce administrative burden or losses.
Contact:
24/7
Medical Billing Services
Tel:
+1 888-502-0537
Comments
Post a Comment