HealthPlan Data Solutions Helps Pharmacy Benefit Managers Reduce Costs and Improve Accuracy of Patient Claims

Healthplan Data Solutions (HDS) is out to help solve one of the most complicated issues in healthcare today—the ever-increasing cost of prescription drugs.

It has been a 13-plus-year journey for HDS’s founders—pharmacists and entrepreneurs who are so passionate about improving patient care and reducing costs that they took on the massive problem of pharmacy expenditures.

The challenges facing the distribution chain for prescription drugs.

The distribution chain for prescription drugs is multi-layered and extremely complex. Health insurers, drug manufacturers, and pharmacies are all part of the process. Central to this distribution system are pharmacy benefit managers (also known as PBMs).

Pharmacy benefit managers are the companies contracted by commercial health plans (like Humana or United Healthcare) and government payers (states and federal agencies, Managed Medicaid, Medicare Advantage plans) to administer the health insurer’s prescription drug benefit plans. Before PBMs existed, there was no entity to standardize and help these complex agreements. However, as the prescription drug supply has grown in complexity, reporting and auditing processes have not kept up.

“The process as it stands today is very opaque,” said John-Michael Loke, Chief Revenue Officer of HDS. “There is a lack of transparency and a perceived lack of accuracy in pharmacy payment. The process needs oversight, and we are that oversight tool.”

Current pharmacy benefit audit and analysis tools are retrospectives in nature. Claims are paid and then reviewed for accuracy. When an error creates an overpayment situation, it becomes a cumbersome and labor-intensive process of correcting the records and clawing back the overpayment. This costs time and money and adds to the overall cost of prescription drugs. HDS solves these challenges by delivering a prospective review of pharmacy claims in a pre-pay environment, establishing itself as the country’s leading expert in pharmacy benefit payment integrity solutions.

HealthPlan Data Solutions delivers greater accuracy and value to payers and their pharmacy benefit managers (PBMs).

HealthPlan Data Solutions’ analytics software solution, ClaimScan™, reviews 100 percent of any claim file down to the line level to identify payment errors and take immediate action to fix those errors. HDS’ proprietary data-mining platform gives their clients actionable intelligence to the inner workings of the entire pharmacy benefit chain, thus driving out error, reducing cost, and improving health outcomes

“We are the only solution in the space that performs payment integrity as claims are occurring in near real-time,” Loke said. “When a claim is inaccurate, HDS flags the claim, details the specifics of the error, and  the claim doesn’t get paid until the problems get fixed.”

HDS clients include National Health Plans, Managed Medicaid and Medicare Advantage payers, States, Federal Health Plans, Blue Cross& Blue Shield plans, and other commercial payers.

In 2018, HDS gained the full attention of the marketplace by identifying more than 180 million dollars in overpayments for Ohio Medicaid. Since then, HDS has continued to grow rapidly.

 HealthPlan Data Solutions is continuing to scale support of the state, federal, and national commercial clients as a rapidly growing company.

“Pharmacy benefit payment accuracy and transparency is a national problem affecting payers both large and small,” Loke said. “The emphasis on adherence to contract terms and to demonstrate oversight is a driving energy now—at the federal and state level. There is pressure on the pharmacy benefit managers to be more transparent and accurate. We are proving that we can help.”