Managed Care Pharmacist Boosts Drug Replacement, Reimbursement

San Diego—Enlisting the services of a managed care pharmacist may help hospitals increase their reimbursement for chemotherapy agents, according to researchers from the University of Southern California’s Norris Cancer Hospital (NCH). Presenting the findings at the annual meeting of the AMCP, lead researcher Shetal Desai, PharmD, discussed how NCH decreased the number of disputed claims and recovered more than $1 million in drug replacement from manufacturer patient-assistance programs across 18 months after bringing a managed care pharmacist on board.

Specifically, Dr Desai examined the hospital’s process and identified several problems that were leading to disputed claims and lower reimbursement, including:

• Physician chemotherapy orders were not always sent for prior authorization
• The hospital lacked an authorization department that was staffed with clinical personnel who could best respond to payers’ queries and requests for clinical trial information
• There was no centralized department that coordinated patient enrollment in manufacturer-sponsored assistance programs.

In response to these findings, Dr Desai developed a clinically staffed chemotherapy authorization department which included a pharmacist, pharmacy techs, and nurses. In addition, she implemented PyxisConnect technology, which allows for realtime order scanning that is directly routed to authorization staff. Dr Desai also enrolled patients with indications not US Food and Drug Administration approved into patient-assistance programs.

According to Michael Andreski, RPh, PhD, assistant professor of Clinical and Administrative Pharmacy at Drake University College of Pharmacy and Health Sciences, the findings “once again demonstrate the value of timely pharmacist intervention in the medication use process.” He adds that the results “should stimulate similar efforts at other institutions that are greatly needed in our cost-conscious practice environment.”