Specialty pharmaceuticals are on the forefront of medical care, with the ability to cure previously terminal diseases and reduce the pain and suffering associated with certain, chronic illnesses. They almost always are more complex to store, administer and monitor than traditional drugs and requires close healthcare professional supervision. Today, individuals with such illnesses as cancer, rheumatoid arthritis and multiple sclerosis are living longer, and have better quality of life on administering specialty pharmaceuticals. However, these positive outcomes come at great, perhaps even unsustainable cost to the U.S. healthcare system.
Healthcare payers are currently spending almost $100 per member per year on specialty pharmaceuticals, with treatment of one insured costing as much as $400,000 annually. Since 1990, the number of specialty pharmaceuticals approved by the FDA has doubled approximately every five years, with almost 200 drugs currently in use and more than 1000 in development.
U.S expenditures on specialty pharmaceuticals are expected to reach almost $100 billion per year by the end of 2010, almost five times the amount spent in 2001. With hundreds of new drugs in development and new treatment uses for existing ones, specialty pharmaceuticals are likely to remain a major driver of payers' claims expenditures for many years.
SCIOinspire's Specialty Pharma Program delivers a comprehensive and ongoing review of specialty pharmaceutical claim payments, maximizing overpayment identification and recoveries for our clients. In addition, unlike some healthcare audit companies, we flag and report any systemic overpayments identified, so our clients can take action to prevent them in the future.
- Identifying one-off overpayments that can be promptly pursued with little or no review of supporting documentation or discussions with providers
- Identifying and addressing situations that require more extensive auditing through an on-site or desk review of a providers supporting documentation, which may be identified based on factors such as total claims volume, unusual billing patterns and the uses and types of drugs being dispensed
- Reviewing various components of provider contracts, authorization processes, and payment policies and procedures that may be leading to overpayments
- Applying a proprietary 360-degree approach to auditing and consulting to ensure a thorough and comprehensive review designed to maximize overpayment identification and financial recoveries, as well as ongoing advice designed to fix existing problems and prevent future overpayments
- Specialty Pharma Program
- Specialty Pharma Program for Labor Unions
