Prescriber Eligibility®

The Science of Better Compliance

Invalid Prescriber Data is a Genuine Concern for Pharmacy Chains

Medicare Part D prescription drug claims containing invalid prescriber identifiers cost the nation 1.2 billion dollars in the year 2007 alone1. Under intense pressure to rein in costs, the Center for Medicare and Medicaid Services (CMS) is more determined than ever to recoup funds lost to fraud, waste, and abuse in the U.S. healthcare system. Toward that end they are increasing audit and enforcement activities putting increased pressure on sponsors and providers to ensure an active and valid prescriber identifier is submitted on every claim or face costly fines and penalties.

Prescriber Eligibility
Case Study

Top retail pharmacy chain reduced risk by 50% by reducing the number of rejected claims.
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Since May 6, 2013, only individual (Type 1) National Provider Identifier (NPI) numbers have been accepted for electronic claims processing. NPI numbers have to be correct whether the source is from a data vendor, prescription pad, or from the National Plan and Provider Enumeration System (NPPES). Given the staggering number of invalid identifiers and the high fraud susceptibility, pharmacy chains must accelerate their efforts to achieve and maintain precise prescriber data.

The government mandate to proactively manage prescriber data validation and compliance at the point of service, regardless of chain size, presents a daunting task for most pharmacies. Health Market Science’s robust prescriber data solutions help tackle this challenge head on.

Prescriber Eligibility: Compliance as an Integrated Component of the Point-of-Dispense Process

Pharmacist using Prescriber EligibilityCompliance is an essential element in the cultivation of effective patient/customer care. Preventing the submission of erroneous prescriptions by quickly validating a claim at the point-of-service is, therefore, a key objective for our clients. The regulatory environment and variability across prescribers, specialties, and geographic regions, however, makes validating a prescriber’s eligibility in a timely, efficient manner, an operational nightmare. Health Market Science eases the burden of inconsistent information on those responsible for ensuring compliance by placing centralized, accurate, and comprehensive information at their fingertips—without compromising point-of-sale workflow or patient/customer satisfaction.

To realize this goal, Health Market Science's Prescriber Eligibility, ensures real-time compliance checks against all submitted claims before they are transmitted to payers. This streamlined solution, based on data from the Provider MasterFile, is generated via web services and can be configured using a powerful administrative tool tailored to organization readiness and specific business needs, including:

  • Configuration of compliance rules by payer
  • Configuration of compliance rules by state of submission
  • Traceability to source data to support audit defense
  • Daily aggregated reports queried by prescription reference, store, prescriber, payer, or compliance check
  • Summary-level trending reports by chain and store
  • On-demand reporting available via user administration tool
  • Override of rejections for third-party help desk
  • Sanctions flags (e.g., OIG, Medicaid, and GSA Exclusions)

Given the sheer volume of prescriptions filled every day, the pharmacy has become the nation’s thoroughfare for prescriber credential validation. Consequently, part of the pharmacist’s role as caregiver is to police compliance efforts at the point-of-sale. Not only does this feed crucial information to the healthcare database, it also reduces fraud and saves lives.


1Invalid Prescriber Identifiers on Medicare Part D Drug Claims, Office of the Inspector General, June 2010