HDS Combines the Power of Near Real-Time Oversight Technology with Pharmacy Industry Expertise to Lower Prescription Drug Spend for Payers
Increasing payment integrity to reduce the costs of drugs
Today, the company’s flagship product, Claim Scan, is one of the only ongoing pharmacy monitoring solutions on the market that has delivered millions in realized savings to clients during the plan year. It wasn’t easy nor quick, but HDS has become a true market innovator in pharmacy benefit payment integrity helping payers across the country ensure optimal PBM performance and accountability. HDS Markets to commercial payers, government payers, self-funded employers, and more.
Making real-time pharmacy data analytics simple and payment integrity solutions achievable
“Through advanced analytics, we are better organizing and analyzing pharmacy data so that payers of pharmacy benefits can regain the visibility they need to understand how their money is being spent and make informed decisions,” said Jeff Baldetti, Vice President of Product and Marketing.
To understand the enormous impact that HDS is having, it helps to look back at how the prescription drug delivery chain got to where it is.
Back in the sixties, pharmacy benefits managers (PBMs), an intermediary layer in the distribution chain, came about to help insurance companies, self-funded employers, and government payers (state and federal agencies) administer prescription drug plans. PBMs played a vital role in bringing systems and standardization to an industry struggling to administer insurance coverage and claims.
As the market evolved, PBMs began expanding services and gaining significant access to pharmacy data. That data ultimately has provided the PBMs with the leverage to become some of the most powerful organizations in the healthcare market. Today, three major PBMs process about 80 percent of all the prescriptions in the U.S.
“The PBMs have always held the data from both sides of the pharmacy equation. They often know more than the manufacturers trying to get the drugs to market, the patients taking those drugs, and the insurance companies and government agencies charged with paying to cover the drugs,” said Baldetti.
With HDS’s web-based platform, Spotlight, payers can now use advanced analytics and technology to continuously monitor and analyze 100 percent of their claims to identify opportunities for cost savings, cost avoidance, and strategic contract improvement opportunities throughout the plan year.
Case Study: How HDS implemented Claim Scan with near real-time payment integrity to help one plan save $6.8MM in the first year
“We started pulling back the opaque curtain with data access to reveal differences in contracted pricing, plan design implementation, rebates, and discounts that the payers of prescription benefits had no easy way to identify for themselves,” said Baldetti. “Now payers can see their data and use it to effectively assess the performance of their PBM during the plan year.”
Case Study: How Ongoing Pharmacy Claims Monitoring Realized $12.3MM in Savings Over 2 Years
“Over the last ten years, we have developed over 500 rules-based algorithms with our pharmacy team and coded them into our system. With these algorithms, we can pinpoint subsets of claims that require additional review with the client’s PBM, and we can organize it in a way that helps guide them towards a faster issue resolution process,” Baldetti said.
“A key differentiator for HDS is our ability to flag issues when they happen, so instead of waiting for year-end audits, payers can troubleshoot and callout over-payments and discrepancies for immediate review with the PBM,” Baldetti said.
“The market has been asking for unbiased third-party verification of PBM performance with a renewed fervor,” he said. “By providing that, HDS is driving real value for organizations both large and small. At HDS, we firmly believe ongoing monitoring is the future and should be a part of every payer’s payment integrity arsenal.”
