ATLANTA, June 3, 2013 – The Centers for Medicare & Medicaid Services (CMS) Recovery Audit Program is targeting hospital billing patterns for outpatient drugs and its audits have called into question millions of dollars in potential overpayments. To help hospitals mitigate the serious pharmacy compliance and revenue risk of overpayments, and to help identify underpayments, Craneware, Inc., the healthcare market leader in automated revenue integrity solutions, which pioneered technology for verifying pharmacy data in 2008; today announced that it will showcase its advanced Pharmacy ChargeLink® innovation at the American Society for Health-System Pharmacists® (ASHP) 2013 Summer Meeting and Exposition to be held June 1-5, 2013 in Minneapolis, Minn.
One of the opportunities emerging from the Affordable Care Act’s (ACA) focus on transparency is for healthcare leaders to establish a process for pharmacy revenue integrity and data governance across their hospitals and clinics. Widely used drugs, including Herceptin, Remicade and Lupron, are being targeted by recovery auditors (RACs), with strict consequences if claims are not accurate.
Craneware solutions help hospitals be prepared to successfully defend their earned revenue in an audit and as part of this process we study the focal points that RACs are targeting,” commented Craneware COO Derek Paterson. “More than half of the issues being targeted by recovery auditors are pharmacy related. Key among hospital pharmacy’s vulnerabilities are questions about the medical necessity of drugs being dispensed and related documentation, incorrect HCPCS coding, and hospitals billing entire vials when they are deemed multi dose and should be billed as dispensed quantity only. Pharmacy ChargeLink helps identify these potential issues from purchasing data as well as formulary and chargemaster data, and informs on how to bill correctly and avoid the risks of audits.”
Underpayments continue to be a significant, largely hidden problem, from HCPCS coding issues to billing units and charge capture issues, it’s hard to identify these losses without bringing both data sets together and looking at exceptions. Typically all that a pharmacy sees is a chargemaster service code, and they do not know what information that service code relates to in the chargemaster. Craneware is identifying large discrepancies between what pharmacies think is being billed and what is really being submitted for payment.
“One of the tool’s most compelling findings was the volume reconciliation variance between our drug spend alongside revenue and usage data,” said Kathy Lytal, Parkview Health’s Director of Revenue Integrity. “We identified an annual gross revenue variance in excess of $10 million. Pharmacy ChargeLink provided an environment to manage by exception, supporting our ability to clearly identify the individual drugs that were contributing to the variance, and prioritize our process improvement initiatives. Parkview Pharmacy, Clinical, and Revenue Integrity stakeholders partner to identify root cause to improve documentation and charge capture processes. During readiness and post-implementation stabilization of a large electronic health record conversion, coding, billable units, pricing, and charge capture performance variances were identified early allowing the team to resolve build issues and develop action plans to address process and education opportunities” Lytal explained.
“Today, healthcare organizations of all sizes must look closely at their pharmacy data and validate its accuracy,” said Craneware CEO Keith Neilson. “Many health systems don’t realize the sizeable underpayments that occur when they manually manage the numerous points of contact between purchasing, medication-administration, and reimbursement. Data can be lost or degraded anywhere along that path. To enable hospital organizations to efficiently realize the value inherent in the validation of their pharmacy charges, Craneware pioneered an automated solution that supports a proven data governance process for ensuring the accuracy and integrity of pharmacy data.”
Technological integration between hospital, clinic and pharmacy solutions has been rare in the past. Most hospitals struggle to link purchase history data to reimbursement activities and continue to use manual methods such as spreadsheets to manage reviews annually, during which time revenue loss is compounded. Craneware’s Pharmacy ChargeLink software helps healthcare organizations align their pharmacy data across hospitals and clinics, and solve the complex issues inherent in this reconciliation that are unique to pharmacy. Manual processes represent significant vulnerabilities in charge capture. Having technology to analyze the calculations between purchased billable units and billed units easily pinpoints areas to re-capture compliant revenue. While this seems relatively intuitive, hospital system reporting and analytics between formulary procurement and revenue integrity do not provide transparent integration for audit and review. These challenges require automated solutions in order to mitigate compliance risk and achieve earned reimbursement for one of the most costly supplies in healthcare.
Craneware (AIM: CRW.L) is the leader in automated revenue integrity solutions that improve financial performance for healthcare organizations. Craneware’s market-driven, SaaS solutions help hospitals and other healthcare providers more effectively price, charge, code and retain earned revenue for patient care services and supplies. This optimizes reimbursement, increases operational efficiency and minimizes compliance risk. By partnering with Craneware, clients achieve the visibility required to identify, address and prevent revenue leakage. To learn more, visit craneware.com.