The record cited two basic problems:
The challenge concerning confirming Medicaid beneficiaries' private health coverage because of the absence of trustworthy data sources. In the absence of reliable data, approximately 13% of all Medicaid recipients that use unreported primary health policies are actually costing states billions of dollars annually in healthcare expenses that ought to be paid for by a third party.
The issue inherent with the collection of costs from third parties. Retroactive recovery procedures, often regarded as "pay and chase," are really costly, ineffective as well as only able to yield 17% for each dollar wrongly spent.
In an effort to address the issues described in the GAO report, CMS issued guidance to states in a 2008 Budget Brief that requires states to uphold the cost avoidance criterion for pharmacy claims as well as do away with waivers that authorize pay and chase approaches.
Built upon this particular guidance, states have indeed reacted by establishing coordination of benefits (COB) programs which count on self-reported recipient eligibility data and/or on stagnant data accumulated by TPL vendors for pay and chase purposes. That information is definitely incomplete, latent and certainly not sufficient for true cost avoidance. If you want to successfully satisfy CMS' cost avoidance guidelines, a reliable point of sale approach that accesses a real-time nationwide data bank of health care coverage would be called for to cost avoid claims and eradicate the problems attempting to collect monies for claims that states should have not paid to begin with.
In 2008, on behalf of disaster relief initiatives, CMS relied on Syrtis Solutions to deploy a real-time pharmacy cost avoidance solution at the point of service (POS) following hurricanes Ike and Gustav. CMS needed a service that would prospectively cost-avoid pharmacy claims especially for those patients with other health coverage. The solution accessed Surescripts' Master Patient Index (MPI), which houses in excess of 230 million lives, to prospectively identify individuals having other health coverage at the point of sale.
The Emergency Prescription Assistance Program (EPAP) was a success, cost avoiding 15% of all claims in sub-second transaction times with zero timeout issues and, most importantly, without involving workflow adjustments at pharmacies.
