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How a PBM Adds Value to the Paper Bill Review Process — Financially and Clinically
Paper bills are a common practice in workers’ compensation due to out-of-network pharmacy fills, for instance, or medications dispensed from a physician office.
“When we say ‘paper,’ it’s a generic term for anything that’s not coming to us from a real-time, point-of-sale environment, like what you’d see at an in-network retail pharmacy,” explained Viviana Brantley, chief operating officer, MyMatrixx by Evernorth (MyMatrixx).
Because these bills can come from different sources and hold different pieces of information, it may be difficult for payers to understand the amounts they are being charged, what services they are charged for, what happens if there is missing information on the bill and what is happening to the bill data.
All of that should be answered in bill review, so having the right bill review partner can make a big difference financially.
Unlike a traditional bill review vendor, MyMatrixx takes prescription bill review further as it works to eliminate administrative overhead and provide its clients with exceptional clinical management.
Paper’s Messy Place in a Clean Digital World
Viviana Brantley, Chief Operating Officer, MyMatrixx by Evernorth
When payers receive paper bills, they submit them to their bill review partner.
“We accept bills through any method that is most convenient for the client,” said Liane Fritch, operations director, MyMatrixx. “They can send them through electronic connections directly with us or the billers, or by fax, email or even snail mail, if that’s their preference. This eliminates the worry around digitizing every bill that enters their system.”
Not all bills come complete, however, and how the missing information is handled is another distinction between the MyMatrixx approach and a typical bill review vendor’s.
“Notably, 30% of the paper bills we receive have missing or invalid information,” Brantley said. “That could be something like a missing prescription number, quantity or prescriber name.”
A typical bill review vendor will just send it back to the provider to complete — which it may or may not do before returning it to the bill review vendor. Uncorrected bills can circle between the provider and the bill review vendor multiple times, leading to additional charges for the payer.
Through its clients’ data, MyMatrixx sees bills go back and forth with other bill review vendors an average of three times.
“Payers are literally paying for this inefficiency over and over again,” Fritch said.
In contrast, when MyMatrixx receives a bill with missing information, it has an internal team that calls providers and works to complete the missing information the first time around.
This means that MyMatrixx is working for its clients to eliminate some administrative overhead because, when applying its processes, the adjuster or client touches the bill only once.
“For us, it’s not about volume. It’s about accuracy and managing the paper bill process and the bill data to make the process easy and clear for clients,” Fritch said.
A Clinical Eye Makes All the Difference
Liane Fritch, Operations Director, MyMatrixx
It’s one thing to review bills for monetary accuracy, and all billing facilities will reduce it to a fee schedule (which is most often different than contracted rates). What really adds value for a payer is a partner that provides paper bill management with a clinical eye on the process.
“A bill is more than just a request for payment; it’s a valuable source of data that we can leverage to assist our clients and the injured workers they serve. That’s the true value a PBM brings to the process,” Brantley explained.
With every paper bill, the MyMatrixx team ensures that the prescription aligns with evidence-based guidelines and industry best practices. It analyzes the data against the appropriate formularies and looks for drug-on-drug interactions, generic alternatives and more. All this information helps MyMatrixx make informed recommendations to its clients to better manage their pharmacy benefits and maximize adjuster efficiency.
Patient safety is the goal for MyMatrixx, and this clinical focus places the injured worker at the center of care.
“Beyond making sure the injured worker is receiving the right drugs at the right time,” Brantley added, “we conduct outreach to physicians … to inform and recommend alternatives to help manage and reduce an injured worker’s overall risk related to their prescription utilization. With this comprehensive approach, we help our clients effectively manage costs while prioritizing patient safety.”
Finding Your PBM Partner
Paper bill management does not need to be a chore for payers. Compiling the bills, pulling the information and addressing the clinical side of the prescriptions are some of the ways MyMatrixx simplifies the process for its clients.
This smooth and seamless process continues for bills that include both pharmacy and medical charges from services such as hospital visits, doctor visits or physical therapy.
As Fritch explained, “When it comes to the mixed services bills, we have an automated bill-splitting technology that eliminates the need for manual sorting. This speeds up the intake process and adds more efficiency for clients.
“Once the bill is split, we process the pharmacy charges and direct the non-pharmacy charges to the client’s contracted bill-review company,” Fritch continued.
Further, most bill review companies focus primarily on state regulatory fee schedules and basic claim eligibility — both of which are important. MyMatrixx, though, also provides customizable edits and recommendations for its clients.
“By looking at factors such as drug type, cost, quantity, prescribing doctor, refill frequency and pharmacy usage patterns, we give our clients the ability to choose which drugs they want us to automatically pay versus which ones require authorization,” Brantley explained.
She continued, “By leveraging our expertise and technology, we empower our clients to focus on their core competencies while we manage the complexities of their specific pharmacy management requirements. This enables them to save time, reduce costs and achieve better results.”
To learn more, visit: https://www.mymatrixx.com/pbm-solutions.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with MyMatrixx. The editorial staff of Risk & Insurance had no role in its preparation.
