Public Sector Partners helps Texas save millions through pharmacy claims processing services
UMass Medical School affiliate Public Sector Partners (PSP) will continue to help long-term care facilities (LTC) in Texas save millions of dollars through a contract for Medicare Part D claims processing services that was renewed this fall. In the new five-year agreement, PSP, in collaboration with Commonwealth Medicine (CWM), will provide these services to 21 LTC facilities in the state.
“We will continue to maximize the number of Part D claims that are accepted and paid by prescription drug plans, which will, in turn, maximize reimbursement revenue for these facilities,” said PSP Pharmacy Claims Manager Allison Langhill. During the first contract period with Texas, which ran from 2006 to 2010, this program recovered more than $94 million in revenue from Medicare Part D for these LTC facilities. “Our goal is to exceed this number during the next contract period,” said Langhill.
Medicare Part D is the federal prescription drug insurance plan that was implemented in January 2006 to subsidize the costs of prescription drugs for individuals who are covered by Medicare, the federal health insurance program for people age 65 and older, people under age 65 with certain disabilities and people of all ages with end-stage kidney disease. The Part D program, which was enacted as part of the Medicare Prescription Drug, Improvement and Modernization Act of 2003, is optional and covers both brand-name and generic prescription drugs at participating pharmacies through one of 30 affiliated prescription drug plans or a Medicare Advantage plan.
The development of PSP’s Part D claims processing services in 2006 involved collaboration with CWM’s Clinical Pharmacy Services (CPS) division on a pharmaceutical component. As a result of that collaboration, the PSP claims processing team includes a dedicated CPS pharmacist. “This is a great example of cross-enterprise training and collaboration,” said Wendy Berube, a CPS consultant pharmacist who has been working with the PSP Part D team since 2006. “I provide pharmacy expertise to not only the PSP team, but to the long-term care facilities we service.”
PSP’s Part D claims processing services include collecting and analyzing drug plan data, reviewing claims against drug formularies or preferred drug lists, facilitating electronic submission of claims to Part D drug plans, troubleshooting, and resolving outstanding and rejected claims. PSP signed its first contract with the Massachusetts State Office of Pharmacy Services in 2006 to provide these claims services to 17 LTC facilities in Massachusetts.
For the Massachusetts State Office of Pharmacy Services, which coordinates the claims for those 17 LTC facilities, approximately 12,000 claims are processed by PSP each month. Approximately 20,000 claims are processed each month for the LTC facilities in Texas, which, according to Berube, has one of the largest populations in LTC facilities in the nation.
When claims are submitted, they are reviewed and, once validated, billed to the appropriate prescription drug program. For any claims that have errors—an average of approximately 30 percent of all submissions—pharmacy technicians review the errors and resubmit corrected claims to the various prescription drug plans affiliated with Part D.
“These technicians work closely with the facilities’ pharmacy staff to help them resolve those errors,” said Berube, who helps oversee this team and also acts as a liaison between LTC facilities’ and state pharmacy staffs. “This is a valuable service for these facilities. In many cases, staffing is lean and individuals are overworked, so the services we provide cover things they can’t get to, which allow them to focus on caring for their patients.”.
About Public Sector Partners
An affiliate of UMass Medical School and its Commonwealth Medicine division, Public Sector Partners Inc. (PSP) is a nonprofit health care management organization that offers a full array of program-management and consulting services to public health agencies and private organizations. It provides a variety of Medicare Part D services, administers a state pharmacy assistance program and operates a member and provider services call center. PSP also administers pharmacy programs through its pharmacy benefit management company,MedMetrics Health Partners Inc. For more information, visit www.publicsectorpartners.com.
About Clinical Pharmacy Services
Part of UMass Medical School’s Commonwealth Medicine division, Clinical Pharmacy Services (CPS) offers comprehensive prescription drug management services to state and federal agencies, pharmacy benefit managers, managed care organizations and correctional health programs. First established in 1999 to provide drug utilization review services for Massachusetts Medicaid, CPS has become an industry leader in both service delivery and consultancy. For more information, visit www.umassmed.edu/cps.
