PHARMACY

Wrong provider data is a huge burden on pharmacies

BY Brian Eidex and Jill Regan

Pharmacies dedicate countless hours and unquantifiable resources to maintain the integrity of both their data and provider data that’s channeling behind the counter. Patient safety requires it; regulatory bodies demand it. But according to the last available study done by the Office of the Inspector General (OIG) in 2013, the National Plan and Provider Enumeration System provider data was inaccurate on 48% of records. Even worse, records found in National Provider Identifiers (NPI) and Provider Enrollment, Chain and Ownership System were inconsistent 97% of the time.

If you’re shaking your head in frustration over that figure, you are not alone. Pharmacies understand there’s a hefty price of provider data gone bad — both from quality and resource allocation perspectives — and aren’t sure where to turn.

The OIG notes, “Inaccurate, incomplete and inconsistent provider data coupled with insufficient oversight place the integrity of the Medicare program at risk and present vulnerabilities in all health care programs.”

The problem

Healthy, successful operations depend on accurate, current data about every single prescriber. Unfortunately, provider data is continually changing, and at an alarming rate. According to LexisNexis, active healthcare practitioner data changes in just one week include:

  • 33,000 primary addresses,
  • 3,300 names,
  • 1,750 phones
  • 1,500 fax numbers,
  • 86,000 state license expirations,
  • 17,000 state license statuses,
  • 7,000 qualifiers, and
  • 1,000 DEA numbers

Before a pharmacist fills a prescription, he or she needs to verify the provider information on each federal and state Web site. The more steps that are involved in this process, the more room there is for error. In some cases, pharmacy staff glances quickly at the registry, and selects the wrong prescriber for the insurance claim, resulting in the payers recovering payment. Additionally, not having full access to sanctions at the state or federal level could result in payment recoveries, leading to substantial financial impact for the pharmacy. Most damaging, selecting a prescriber with the wrong prescriptive authority could result in patient harm as well has significant fines from the Drug Enforcement Administration (DEA).

 

The effects

Many errors in provider data points are simply demographic or affiliative issues that erode over time to become outdated or inaccurate. When a pharmacy isn’t taking a proactive role to monitor the quality of its data, operational effectiveness will be compromised. Any and all information-powered functions are at risk if the information on file isn’t current or complete.

In other situations, pharmacy staff battles customers’ increasing accessibility of prescriptions in general and pain-reducing medications in particular. The United States is indeed experiencing a crisis of huge proportions in the opioid epidemic, which spurs addicts to exploit weaknesses in the prescribing system in supplying their addiction. According to the Department of Health and Human Services (HHS), 11.5 million Americans misused prescription opioids in 2016, and 2.1 million suffered from a reported opioid use disorder. Inaccurate provider data is a liability in the successful monitoring and appropriate distribution of potentially dangerous narcotics.

The scope of provider data is enormous, and manually monitoring this data is a tedious and costly process for pharmacy employees who strive to operate diligently in increasing profits and staying ahead of the competition. To say nothing of recovered payments and prescriptive authority violations, the financial burden of keeping data clean is a heavy one.

Some seek their solutions in state license board data, but that information is not always as reliable or accurate as one would hope. The data integrity is compromised by differences in the credential acquisition by state and board, credential requirement/recognition differentiation, data availability and data quality control, and federal/state standardization inconsistencies. The manpower required to navigate numerous systems to crosscheck vital information is significant and is viewed as more of a “workaround” than a lasting solution for maintaining data integrity.

The LexisNexis Provider Data MasterFile combines healthcare-specific, public and private proprietary records from about 2,000 sources to form the largest provider referential database. The scope and breadth of this information are designed to improve completeness, accuracy, consistency, and governance, while access to current records is data-driven and automated to optimize daily integration for pharmacies across the country.

While data is a pharmacy’s greatest asset, its scope is overwhelming. Uncertainty about how to manage the data deluge can have financial implications that impact the success of your operation. If the management of accurate information is spinning out of your control, consider the options for driving not just survival but success.

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PHARMACY

Camber intros generic Tamiflu capsules

BY DSN STAFF

Camber pharmaceuticals has launched its generic Tamiflu capsules (oseltamivir phosphate). The Piscataway, N.J.-based company’s generic of Hoffman La Roche’s drug is indicated to treat and prevent the flu.

Camber’s generic Tamiflu capsules will be available in 30-, 45- and 75-mg dosage strengths in 10-count blister packs.

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PHARMACY

Cigna to acquire ExpressScripts for $67B

BY David Salazar

Health insurer Cigna has entered into a agreement to acquire Express Scripts. The combination of Bloomfield, Conn.-based Cigna and the St. Louis-based pharmacy benefits management company is valued at roughly $67 billion, the companies said — a scale similar to that of the ongoing $69 billion acquisition of health insurer Aetna by CVS Health.

As part of the stock-and-cash deal deal, Cigna will assume roughly $15 billion in Express Scripts’ sebt, with Cigna paying $48.75 and 0.2424 shares of its stock per one Express Scripts share. The companies said that the move is aimed at improving consumer choice in healthcare, providing more coordinated care and improving the value of healthcare dollars.

“Cigna’s acquisition of Express Scripts brings together two complementary customer-centric services companies, well-positioned to drive greater quality and affordability for customers,” Cigna president and CEO David Cordani said. “This combination accelerates Cigna’s enterprise mission of improving the health, well-being and sense of security of those we serve, and in turn, expanding the breadth of services for our customers, partners, clients, health plans and communities. Together, we will create an expanded portfolio of health services, delivering greater consumer choice, closer alignment between the customer and health care provider, and more personalized value. This combination will create significant benefits to society and differentiated shareholder value.”

Once the transaction closes, Express Scripts shareholders will own roughly 36% of the combined company, with Cordani leading it as president and CEO. Express Scripts’ president and CEO Tim Wentworth will become president of Express Scripts, with the combined company’s board comprising 13 directors, four of whom will be independent Express Scripts board members. The combined company will be headquartered in Bloomfield, Conn., with Express Scripts continuing to be headquartered in St. Louis.

The deal comes as the healthcare industry works to find value-focused solutions to rising healthcare costs. In in 2016, the $3.3 trillion dollars in healthcare spending made up 17.9% of the United States’ gross domestic product. Both the Cigna-Express Scripts and CVS Health-Aetna mergers appear focused on personalized care through use of analytics. And where the CVS Health-Aetna merger is aimed at turning CVS Pharmacy into the “front door of health care,” as executives at both companies have said, Cigna’s move is meant to streamline the way healthcare is delivered by physicians while making medical, behavioral, specialty pharmacy and other services accessible through more channels.

“Together, our two organizations will help make the healthiest choices the easiest choices, putting health and pharmacy services within reach of everyone we serve,” Express Scripts’ Wentworth said. “Adding our company’s leadership in pharmacy and medical benefit management, technology-powered clinical solutions, and specialized patient care model to Cigna’s track record of delivering value through innovation, we are positioned to transform healthcare. We will continue to have a distinct focus at Express Scripts and eviCore on partnering with health plans, and together, build tailored solutions for health plans and their members. Importantly, this agreement is a testament to the work of our team and their resolute focus on providing the best care to patients, and the most value to clients.”

As consolidation continues in the industry, smaller players — in particular community pharmacists — are growing concerned about their place in the healthcare world and what these pushes for patient access mean for their patients. On Thursday, National Community Pharmacists Association CEO Doug Hoey said that, as the orgnaization assesses the implications of Cigna’s acquisition, “one thing is clear: Consolidation among health care giants leads to fewer choices for patients and plan sponsors.”

Hoey also registered his skepticism about such deals’ ability to curb soaring healthcare costs.

“Companies make claims of cost savings that will benefit patients and health plan sponsors, but the available evidence from previous consolidations suggests otherwise,” he said. “The merger of UnitedHealth and Catamaran a few years ago, for instance, certainly didn’t change the upward trajectory in health care spending.”

A narrowing field of industry players could have big consequences on patients, Hoey said.

“We’re seeing the growing balkanization of the health care industry — a world in which patients may be forced into a health care kingdom – the CVS-Aetna kingdom, the Cigna-Express Scripts kingdom, the UnitedHealth-OptumRx kingdom, et cetera — where the borders aren’t porous, and patients are stuck with what they get. Depending on where you live, that lack of choice could disadvantage patients who are trapped in inflexible pharmacy and health care networks that dictate the decision-making process for the delivery of care.”

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