Ensuring Patient Copay Program Integrity

Most pharma brands have copay programs to help their patients start and adhere to therapy. As Martha Stewart would say “It’s a good thing” for both the patient and the brand. The result is the patient pays less for their medication with the financial assistance the brand team provides. In return, the brand team is helping their patients, and they get more consistent usage from those patients.? Both parties walk away with significant benefits.

The program supporting the brand must be successful so the brand can grow the business and continue to offer assistance. If the copay reimbursement NCPDP system was a railroad, we’d say it runs on “old rails” because the system is outdated showing many holes. Those holes would not matter if everyone in our society had integrity, but unfortunately, that is not the case.

Many things can happen to derail your program and cost the brands money they could be spending helping more patients:

1)???? Business Rule Oversights: The business rules you thought were active for your program are not working so they are allowing overpayments, double dipping, or ineligible patients to receive your funding.?

2)???? Incorrectly Processed Claims: This can happen at any pharmacy. It’s when the pharmacist simply makes a legitimate mistake and processes the claim incorrectly due to a lack of knowledge or a misunderstanding of the program’s business rules. The result can be either an under or overpayment but the vast majority of the time the result is paying much more for a claim than you should have (coincidence?). This can become a big problem rather quickly if thousands of pharmacists working for CVS are making the same mistakes. There may be no intent to defraud here, just an honest mistake, but if not identified and corrected these can add up quickly.

3)???? Fraudulent Claims: These are claims mostly coming from independent entities where the claims process is altered to benefit the pharmacy. There are at least a dozen ways this can be accomplished by a knowledgeable independent (non-chain) pharmacist. Unless brand teams are checking their 867 sales data against their claims they will not don’t know if the pharmacies who are processing claims are buying that product. Pharmacies faking patients submitting fake claims happen more often than you might think.??

The average copay program will have between 5% to 30% of their claims which would be classified as a “red flag” claim requiring further investigation. In some categories like Dermatology, Diabetes, and ADD /ADHD rates are higher. If you look at your total spend of your program it should be evident what the above three issues could be costing you. Even with all of this activity happening every day, 99% of brands have never done a copay claims audit through an expert objective 3rd party.

It could be because no one is thinking of the need for someone to come in and look over their program for issues, and many times it's just no one knows where the money would come from. No copay program should be put in the market without putting aside enough money to do an annual audit specifically tailored to copay business rules and fraud. Many fund types are recoverable and even for the ones that aren’t you can stop these things from happening in the future which saves you a ton of money.

It is safe to say that if you went into the jewelry business you would not leave the back door wide open and unattended, so why wouldn’t you do it? If you knew enough about what is happening inside your copay program, you might see you are doing the same thing.

The question is: As an overseer of your company’s money (the same funds that pay your salary) whose responsibility is it to ensure the open door is firmly shut?

For a wealth of information on Copay Program Optimization please visit our website: https://alpha1c.com/category/best-practices/

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