The cost of specialty pharmaceuticals is projected to exceed $60 billion annually by the end of this decade - with some 100 biopharmaceuticals from more than 70 manufacturers awaiting FDA approval.

Although payers recognize the need to mitigate these costs, complex contracts, technology limitations and a lack of standardized codes has left them with the difficult task of accurately assessing complex, high-dollar claims under ambiguous reimbursement methodologies, where unit integrity and accuracy cannot be verified. Thus, most overpayments are the result of billing errors related to high-cost injectable medications, which necessitates improved cost-management strategies.

RxI Services

Healthcare payers can now control rising costs associated with reimbursement of prescription injectable medications in physician and outpatient settings using RxI Services, pharmacy cost-management solutions designed to support many leading payers. RxI Services helps manage high-cost injectable medications and specialty pharmaceuticals in oncology, physician, home infusion and renal dialysis settings, validating the clinical, contractual and financial components of a claim. Experienced pharmacists, nurses and policy review professionals who understand claims system complexities, reimbursement methodologies and clinical service issues comprise RxI Services.

How it Works

RxI Services uses experienced clinical pharmacy staff, auditors and proprietary technology to identify and validate actual physician orders and units of medication when indicated. This validation process allows auditors to: perform exact pharmaceutical calculations; reconcile correct product and package size; and verify correct units of high-cost drugs billed. Once correct orders and units are validated, accurate claims pricing for a variety of applicable fee schedules or reimbursement methodologies can be accomplished. RxI's audit and repricing results also help payers incorporate new contract language, to contain costs for these specialty products and services.