Debra Devereaux

Rejected Claims Review–You Gotta Do It!

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The question arises from almost every client, “Why do we have to do daily rejected claims review?” The answer is that there is no better way “to take the temperature” of Part D compliance than rejected claim reviews. Everything that can and will occur happens at Point of Sale. At a minimum you can detect problems with the following:

  • Part B vs Part D
  • Concurrent DUR edits (non-approved by CMS) restricting medication access
  • Inappropriate protected class drug rejects
  • Short cycle dispensing
  • Minimum packaging size
  • NPI processing
  • Transition

Rejected claims analysis is a year-round activity, with special emphasis that will begin in January. Beneficiaries should be able to receive the Part D drugs they are entitled to, consistent with CMS guidance, from January 1st through December 31st of the plan year.

Processes can be designed to organize and streamline the review so that the most relevant and consequential rejects are included. With consistent and thorough reviews, the organization has a foundation for healthy Part D compliance.

 

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Debra Devereaux

About Debra Devereaux

Deb Devereaux is Senior Vice President of Pharmacy and Clinical Solutions at Gorman Health Group (GHG). In this role, she is responsible for leading a team of pharmacists and business analyst consultants with broad health plan, Centers for Medicare & Medicaid Services (CMS) and Pharmacy Benefit Manager (PBM) experience. Deb brings GHG clients more than eight years of Medicare Part D operations expertise. Read more

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