COLUMBUS, Ohio: Rivera, the industry’s leading pharmacy payment integrity company, today released the first published industry research dedicated to continuous oversight of pharmacy claims. The state of pharmacy payment integrity draws on direct insights from 14 health plans, collectively covering more than 26 million lives across commercial, Medicare, and Medicaid lines of business.

The headline finding: pharmacy claims errors are both frequent and largely undetected. Fifty percent of pharmacy executives surveyed said claims issues occur frequently at their organizations, with another eight percent reporting almost always. The traditional oversight model these plans rely on, a retrospective PBM audit that samples claims 12 to 24 months after they are paid, is not built to catch those issues in time to act on them.

"Pharmacy leaders have known for years where their oversight runs thin. Most could tell us exactly where those gaps sit. What the industry has been missing is a model built to close them at scale," said Ron Hamm, CEO of Rivera. "Pharmacy payment integrity is that model, and the plans that adopt it now will set the standard the rest of the industry will have to meet."

Key findings

• 58 percent of pharmacy executives said claims issues occur frequently or almost always at their organizations.
• Traditional PBM audits leave a 12-to-24-month gap between when an adjudication error begins and when it is identified.
• Pricing benchmarks and lesser-of-logic compliance ranked as the top continuous monitoring priority (24 percent), followed by performance guarantees and contractual terms (22 percent) and benefit and utilization controls (20 percent).

Alongside the research, Rivera also released a 13-question pharmacy oversight assessment. The diagnostic lets health plan leaders benchmark their own oversight exposure in under two minutes with no data sharing, vendor onboarding, or internal project lift required.

The full report is available here.

About Rivera

Rivera is an independent pharmacy payment integrity company that helps health plans and employers verify that pharmacy claims are adjudicated according to benefit design, contract terms, and regulatory requirements. Through continuous monitoring of 100% of pharmacy claims, Rivera identifies overpayments, resolves root causes to prevent recurrence, and delivers data that strengthens PBM negotiations. Rivera is not affiliated with any pharmacy benefit manager. Learn more at riverarx.com.

Fonte: Business Wire