In a partnership aimed at helping both insurance carriers and employers, out-of-network pharmacy benefit management (PBM) specialist Progressive Medical and StoneRiver Pharmacy Solutions will make available a combined electronic service to aid in correctly identifying payers for out-of-network pharmacy benefits.
Focused on the workers’ compensation market, which has a high percentage of claims for prescription medications, the partnership intends to provide cost savings both by reducing the length of time it takes for pharmacies to get paid and reducing the costs associated with paper-based claims processing.
"Patients going out of network for their prescription drugs is a major pain point for payers in workers compensation," said Tron Emptage, chief clinical and compliance officer for Progressive Medical. “Progressive Medical continually seeks new ways to help its clients contain costs.”
Total costs for prescription drugs in the United States have risen dramatically in the past five years, from just over $200 billion in 2005 to $300.1 billion, according to research by IMS health. That growth is not expected to slow in the coming years and the combined automated prescription management solution from the two companies is aimed at keeping patients in-network for closer management of both medication costs and patient outcomes.
One client that has put the solution through its paces as a beta site, the Texas Association of School Boards Risk Management Fund, has already realized cost savings. “Each year, the Fund handles a significant number of workers’ compensation claims,” said Herman Wilks, department director of workers’ compensation claims for the organization. “Pharmacy expenses account for a significant portion of the medical costs on these claims. We have demonstrated that this partnership enables the Fund to dramatically reduce pharmacy costs by streamlining adjudication of what would traditionally have been out-of-network invoices.”
At the heart of the partnership is a system that marries the services Progressive offers with StoneRiver’s network for processing workers compensation pharmacy claims. The network comprises more than 60,000 pharmacies nationwide, and when combined with StoneRiver’s P2P Link service provides a transaction hub linking payers with providers.
In this partnership, when pharmacies are unable to identify the appropriate payer, they submit prescriptions associated with Progressive clients’ workers’ compensation prescription claims to StoneRiver. StoneRiver then transmits an alert to Progressive Medical, which then reviews the prescriptions for eligibility and applies real-time drug utilization review edits. Progressive Medical returns their results to StoneRiver, which in turn completes the adjudication and transmits the response to the pharmacy.
