BIRMINGHAM, Ala., Sept. 20, 2012 /PRNewswire/ -- DST Health Solutions, announced today the availability of its Medical Drug Management Service (MDMS) solution, which supports health plans in properly editing and paying specialty medical drug claims to help reduce compliance missteps and overpayments to providers. Health plans face extraordinary challenges to lower costs and enhance service, while improving the quality of healthcare delivery, outcomes and safety.
Over the past few years, specialty pharmacy expenditures have grown significantly. Current legislation stemming from healthcare reform has increased the level of scrutiny facing health plans and other mandated entities that report their level of drug spend to the Centers for Medicare & Medicaid Services. The increase in oversight by the U.S. Department of Health & Human Services Office of Inspector General (OIG) is increasing fraud and abuse investigations, and with the rise in medical spend for specialty drugs, significant financial penalties can be levied against healthcare organizations that fail to meet the standards.
"Given the increased intricacy, sophistication and escalated number of new specialty medications, health plans require new clinical competencies to avoid compliance errors and overpayments to providers," said Mehrdad Shafa, MD, MMM, CMQ, consultant for DST Health Solutions. "DST understands the complexity of the situation facing health plans and the level of education and insight required to remain abreast of these quickly changing mandates. MDMS addresses these challenges by properly editing the specialty drug claims, minimizing errors, improving safety, enhancing regulatory compliance, and improving member and provider satisfaction."
MDMS supports health plans' operational issues by properly editing and paying specialty medical drug claims without disrupting their current administrative systems.
Traditionally, specialty drugs claims processing has been very inefficient due to inherent coding issues and scarcity of sophisticated expertise to establish medical necessity. The vast majority of the claims for specialty drugs are manually processed, creating significant potential for errors. It is estimated that between 15-20 percent of the specialty drugs costs are due to health plans' inability to make medical necessity determinations.
"MDMS provides an automated solution to more effectively and efficiently review medical drug claims processed under an individual's medical benefit, identifying claims in which a drug was coded or potentially prescribed incorrectly as determined by the application of appropriate clinical edits based specifically on the patient and their diagnoses," said Jonathan Boehm, President and CEO, of DST Healthcare and Argus Health Systems, both wholly owned subsidiaries of DST Systems, Inc.
While retail prescription drug trends are stabilizing for the first time in several years, the cost of specialty drugs (injectables and biologicals) is up more than 20 percent since 2008, and has become one of the top – and most costly – concerns of health plans. One example of potential incorrect treatment or claim submission error uncovered by MDMS for a current DST customer revealed a claim for a common anti-inflammatory medication submitted for a dose of 586 units (5,860mg of the drug). Treating the condition reported on the claim, with this dose, would require the weight of the patient to equal greater than 4,000 pounds.
Further evidence of overpayments came from an August 2011 report from the OIG which detailed an audit highlighting overpayments by a Medicare Advantage plan to providers for outpatient services. According to the OIG, providers were overpaid by approximately $6.8 million from January 1, 2006 through June 30, 2009.
Proper claims payment and medical appropriateness may prevent triggering an audit by OIG. In a situation when a health plan is selected for an audit, MDMS information may assist in preventing fines or negative publicity.
To learn more about DST Health Solutions, go to www.dsthealthsolutions.com.
About DST Health Solutions
DST Health Solutions, LLC delivers systems and services that help improve efficiency, increase speed to market, as well as facilitate medical cost management and price containment. Our clients include commercial health plans, consumer-directed plans, government programs (Medicare Advantage, Medicare Part D and Medicaid) and physician practices. DST Health Solutions' enterprise applications and outsourcing services include claims processing, member and provider management, benefit plan management, new product development, care management and medical management, and decision support/analytics. DST Health Solutions is a wholly-owned subsidiary of DST Systems, Inc. For more information about DST Health Solutions, contact 800.272.4799, email firstname.lastname@example.org or visit www.dsthealthsolutions.com.
About Argus Health Systems, Inc.
Argus is a leading independent provider of healthcare information management services supporting commercial, Medicaid and Medicare Part D with a business model that provides full disclosure and transparency. Argus serves a wide range of clients and key healthcare organizations, including managed care organizations, pharmacy benefit managers and pharmaceutical manufacturers.
The information and comments above may include forward-looking statements respecting DST and its businesses. Such information and comments are based on DST's views as of today, and actual actions or results could differ. There could be a number of factors affecting future actions or results, including those set forth in DST's latest periodic financial report (Form 10-K or 10-Q) filed with the Securities and Exchange Commission. All such factors should be considered in evaluating any forward-looking comment. The Company will not update any forward-looking statements in this press release to reflect future events.
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