Medicare Part D >> Claims Evaluation

Prospective and retroactive claims audits are central to a Medicare company’s managing costs.  Claims audits and reviews do not cost!  They reduce costs and increase benefits. To maximize savings, all savings need to be evaluated. 

ECT provides claims evaluations for the industry using out data management engine to provide the benefits you need.

For Medicare Plans:  Claim evaluation services will for plans include:

  • Paying claims that should have rejected.
  • Rejecting claims inappropriately and the liabilities in gerent in access to care
  • Paying pharmacies incorrect rates
  • Non collectability from CMS.

ECT has provided extensive reviews with large savings.  For example, for one plan, ECT was able to increase Medicare benefits corrdination by over $10 million. 

For Pharmacies:  Claim evaluation services will for plans include:

  • Claims reviews are focused on ensuring plans reimburse pharmacies for all claims files.
  • The review provides plan evaluations to determine:
    • Plans which should not be accepted because of low pay rates, high maintenance associated with the plans and the lack of support from the plans
  • A claims review can also be used to target FWA both internally and from associated providers and beneficiaries.

ECT understands the issues impacting pharmacy profitability and our claim revues drop to your bottom line.

For SPAPs:  Claim evaluation services will for these governmental plans are focused on recovery.  ECT consultants have extensive experience working with the issues associated with Medicaid and other state assisted drug program. 

  • These reviews have a two pronged approach. 
    • For Medicaid plans where the SPAP pays first, ECT has found ways to improve collectability by reviewing eligibility issues for claims paid.
    • The data engine evaluates the claims submitted to plans and the payments received.  For many plans, Medicaid secondary payer claims for ignored or given low priority. 
  • ECT consultants have been able to double the acceptance rates of these claims, saving the states millions of dollars