WESTERVILLE, OH – In a partnership aimed at helping both insurance carriers and employers, out-of-network specialist Progressive Medical and StoneRiver Pharmacy Solutions announced yesterday the broad availability of a combined electronic service that will aid in correctly identifying payers for out-of-network pharmacy benefits.
Focused on the workers’ compensation market, which has a high percentage of claims for prescriptions medications, the partnership intends to provide cost savings both by reducing the length of time it takes for pharmacies to get paid and reducing the costs associated with paper-based claims processing.
One client who put the solution through its paces as a beta site, the Texas Association of School Boards Risk Management Fund, has already realized cost savings. “Each year, the Fund handles a significant number of workers’ compensation claims,” said Herman Wilks, department director of workers’ compensation claims, Texas Association of School Boards. “Pharmacy expenses account for a significant portion of the medical costs on these claims. We have demonstrated that this partnership enables the Fund to dramatically reduce pharmacy costs by streamlining adjudication of what would traditionally have been out-of-network invoices.”
At the heart of the partnership is a system that marries the services Progressive offers to its workers’ compensation insurance companies with the prescription billing services StoneRiver provides to more than 55,000 pharmacies nationwide. When pharmacies are unable to identify the appropriate payer, they submit prescriptions associated with Progressive clients’ workers’ compensation prescription claims to StoneRiver. StoneRiver then transmits an immediate, real-time alert to Progressive Medical, which then reviews the prescriptions for eligibility and applies drug utilization review edits. Progressive Medical returns their results to StoneRiver, which in turn completes the adjudication and transmits the response to the pharmacy.
"This initiative eliminates operational burden for our pharmacy clients while enabling Progressive Medical to demonstrate greater efficiencies by significantly streamlining the out-of-network adjudication process,” said Emry Sisson, COO of StoneRiver. “By leveraging our technology and pharmacy relationships, we are able to help Progressive Medical achieve its objective of reducing loss costs for their clients without impacting our pharmacy clients.”
The partnership provides cost savings through the reduction of manual processing of paper invoices. In addition, paper invoices are not subject to payers’ real-time drug utilization review or formulary edits. Through the StoneRiver-Progressive solution, the majority of paper invoices can now be processed electronically and edits applied in real-time, streamlining the process and helping to ensure appropriate pharmaceutical utilization.
"StoneRiver Pharmacy Solutions was the ideal partner for this program because of their unique relationship with pharmacies and their willingness and ability to co-develop this unique technology to bring about greater efficiency and cost savings," said Tron Emptage, Chief Clinical and Compliance Officer for Progressive Medical. “This program will allow us to dramatically reduce out-of-network pharmacy expenses for our clients that choose this program.”
