Prescriber Eligibility
An environment of zero tolerance requires immediate risk mitigation.
Many of the healthcare industry’s most pressing compliance challenges converge at the pharmacy dispensing process. Mistakes made in a split second can unwittingly abet fraud, waste and abuse (FWA) and pose the threat of significant financial penalties or fines.
Given the voracious appetite for exposing FWA in the heavily burdened healthcare system coupled with the high cost of bad publicity, pharmacies can’t afford to depend on Pharmacists and internally generated data bases under intense regulatory scrutiny. Executive management and especially Chief Compliance Officers (CCOs) need assurance they have state-of-the-art compliance solutions that can be controlled centrally to insure proper processing of their real-time Rx without compromising pharmacy workflow and point-of-service customer satisfaction.
Prescriber Eligibility is more than a prescriber verification tool. The ability to process historical claims data gives you quantitative information that can help determine the financial impact of non-compliant claims submissions and potential areas for audit.
Reduce the risk of processing payments to invalid prescribers.
HMS Prescriber Eligibility (PE) is a compliance solution that checks pharmacy claim data retrospectively or in real time. The application responds with informative error codes which include checks on:
- State Licensure and Prescriptive Authority
- Controlled Substance Violations
- Deceased Doctors
- State Medicaid and Federal OIG Exclusions
- Invalid Prescriber IDs
Reduce your go-forward risk of state, federal, and third party payer non-compliance
- Identify areas of non-compliance based upon a particular state’s dispensing and claims submission requirements
- Determine annual financial impact of non-compliant claims submissions
- Identify the potential for audit and possible FWA by geographic area and/or a particular provider
- Make intelligent business decisions such as determining how to reduce claim submission non-compliance and reclaiming FWA funds
- Identify areas where there are data challenges