The key to financial success is expertly managing a sponsor’s adjudication, creation, and maintenance of prescription drug events (PDEs). A common misconception in the industry is that having a low PDE rejection rate indicates PDEs are being accurately adjudicated. In reality, PDE adjudication is a complex, multifaceted process relying on a large array of components such as plan benefit data, CMS compliance regulations, enrollment data, and comprehensive claims history. A minor issue in any of these components will lead to inaccurate PDE adjudication. This directly impact a sponsor’s Part D financial reconciliation.
Understanding and creating a process that allows for efficient, transparent oversight is crucial for financial success. FutureRx offers robust software that allows for oversight of the entire adjudication process, not just the simple CMS rejection rates. This allows any potential process gaps to be quickly identified and resolved with minimal dedicated resources. FutureRx’s PDE experts designed the application to align with all PDE-related government guidance, rules, and regulations.
Analysis, calculation, and validation of the Medicare PDE; ensure timely and accurate PDE file submissions; PDE edit resolution; analyze and reconcile PDE entries rejected by CMS, including those related to eligibility and PDE calculations; find trends in rejected records (including claim processing) and make recommendations for resolution (isolate and mitigate); manage PDE file generation process from end to end (cycle generation, executing PDE load and extract programs, file quality control, file submission to CMS or clients); understanding client’s Medicare Part D coverage and benefit plans in order to analyze the accuracy of PDE records; monitor claim activities to ensure inclusion of all appropriate claim records, adjustments, and deletions of the data prior to submission; and review TrOOP balances to ensure claims and balances are appropriate with benefit design parameters.