Payer of last resort providers are challenged with the difficult task of recovering payments when primary coverage
information is not presented by the recipient at the time services are rendered. For a multitude of reasons, many
recipients do not share other coverage information or are unaware that other coverage exists.
Without technology at the point of sale to prospectively identify other
coverage, payer of last resort providers
must accept claims and use manual pay and chase processes to retrospectively identify and track down primary
payers for reimbursement.
Unfortunately, these traditional recovery processes are inefficient, expensive and produce recovery rates of less
than 17% of the dollars actually billed to primary payers.
ProTPL, a real-time point of sale cost avoidance service, was developed by Syrtis Solutions to support the cost
avoidance and recovery needs of the payer of last resort market. The company's founders, comprised of industry
veterans with experience in pharmacy claims processing and claimant recovery processes, recognized that the
market needed a technology-based solution to improve recovery.
Traditional recovery processes recover less than 17%.
ProTPL accesses Surescripts' master patient index (MPI) utilizing industry standard transactions at the point of
sale. The program has identified that between 6% - 14% of all claims submitted under payer of last resort health
plans have other pharmacy coverage.
Integration of ProTPL into the pharmacy adjudication process results in the real-time identification of claims that have
other coverage. These claims are immediately redirected by the
processing pharmacy during adjudication and cost
avoided rather
than necessitating retrospective post-payment recovery process. In addition, captured information
is added to COB processes for future claims payments, producing a sentinel effect.
As an additional benefit to payers, information obtained through the program can be used to identify and recover
earlier pharmacy claims and used to discover other medical
coverage information to support medical claims
recovery efforts.
Syrtis' proprietary software processes transactions in sub-seconds through standard pharmacy transaction sets
and is seamlessly integrated into any pharmacy benefit management program. The application eliminates provider
and patient disruption and improves patient care by ensuring that primary payers have complete claims history.
Our new technology recovers claims that
until now would be considered uncollectable.
ProTPL can be customized based on each payer's unique needs.
The traditional model dynamically routes
identified claims to the Syrtis Decision Support (SDS) system and queries Surescripts' master patient index. If
other health information is found, the SDS returns correspondence to the pharmacy denying the claim. If no other
health information is found, the SDS routes the claim to the payer's PBM.
As an alternate model, instead of denying the claim when other health information is found, the data can be
captured and stored in the Syrtis Information Bank (SIB) and routed to the PBM for adjudication. An indicator flag
notifies the PBM that other health information exists and Syrtis provides a user interface for customers to access
the information for retrospective recovery efforts.
The ProTPL program has been designed as a seamless,
turn-key operation that allows payer of last resort providers
to begin realizing maximum benefit with no operational disruption.
Program implementation can occur within 60
days with nominal customer resource expenditure.
Syrtis pharmacy professionals manage the integration and
ensure that all processes are completed according to a defined implementation schedule.
ProTPL integrates seamlessly into any pharmacy program.
How does Syrtis Solutions support third party liability regulations?
All private or public healthcare plans, unless specifically excluded by Federal statute, must meet third party liability (TPL) legal obligations to pay claims before Medicaid, or other federally-sponsored healthcare programs.
ProTPL, a service of Syrtis Solutions, enforces TPL obligations to effectively cost avoid pharmacy claims in real-time when other coverage outside of Medicaid exists. In addition to cost-avoiding pharmacy claims, the program helps to identify, recover and cost-avoid medical claims.
What percentage of claims have other pharmacy coverage?
Test data demonstrates that between 6% - 13% of all claims submitted under payer of last resort health plans, excluding Part D, are found to have other pharmacy coverage. Through a prospective cost avoidance solution, claims with other coverage are identified in real-time at the pharmacy point of sale.
In addition to cost avoidance, this information is used to retrospectively recover pharmacy claims previously approved, as well as to identify additional medical dollars that can be recovered both retrospectively and prospectively. The program complies with all federal TPL requirements and reduces inefficient pay and chase methodologies.
Who is ProTPL designed to help?
ProTPL is designed to help governmental agencies, MMIS providers, pharmacy benefit managers (PBM) and payer of last resort health plans reduce manual pay and chase processes that retrospectively identify and track down primary payers for reimbursement.
In addition to a transparent provider model, the program is available as a private-label solution.
How does ProTPL improve recovery for payer of last resort providers?
ProTPL is a technology-based process that efficiently routes recipient claim information to the Surescripts network during real-time pharmacy adjudication.
When other health coverage is found, the claim is denied and the
pharmacy receives the correct primary coverage information in order to route the claim to the primary payer
for processing.
This prospective process replaces manual, retrospective post-payment identification and recovery processes that are expensive and inefficient. ProTPL technology enables the recovery of claims that many payers consider uncollectable.
What are the advantages of accessing the Surescripts network?
The Surescripts network is the nation's first and largest health information network. Unlike other networks, Surescripts provides access to patient information, in real-time, directly from the payer sources.
This ensures that eligibility data is current, thus mitigating false positives that can occur when health plan information is 30 days old.
Will ProTPL disrupt the pharmacy process?
ProTPL is seamlessly integrated into the NCPDP 5.1 and ANSI 12 pharmacy standard to avoid disruption at the point of sale for both the pharmacy and the patient.
After the initial claim is filled, all future claims are cost avoided automatically as the pharmacist has updated the system to prospectively channel the claim to the other health plan.
Can ProTPL be integrated with any claims processor?
ProTPL can be seamlessly integrated with any claims processing system.
Syrtis performs all technology integration functions, mitigating technical resource requirements from the customer and the PBM.
The ProTPL program has been designed as a seamless, turn-key operation that will allow customers to begin realizing maximum benefit with no operational disruption as soon as the program goes live.
As an alternate model, Syrtis offers a full PBM replacement program that combines proven claims processing experience with a technological platform already integrated with ProTPL, in addition to in-depth clinical expertise, a national network of pharmacy providers and excellent customer service and experienced staff.
What implementation options are available?
ProTPL can be customized based on each payer's unique needs.
The traditional model dynamically queries Surescripts' master patient index.
If other health information is found, correspondence is returned to the pharmacy denying the claim. If no other health information is found, the SDS routes the claim to the payer's PBM.
As an alternate model, the program can be set up to "pay and report."
Instead of denying the claim when other health information is found, the data can be captured and stored in the Syrtis Information Bank (SIB) and routed to the PBM for adjudication.
Syrtis provides a user interface for customers to access the information for retrospective recovery efforts.
How long will it take to implement ProTPL? What technical resources are needed?
Program implementation can occur as quickly as 60 days and requires no technical resources from our customer.
The implementation timeline is dependent on the length of time needed to reach an agreement with the current claims processor at various stages of the implementation process. ProTPL uses standard NCPDP 5.1 and ANSI 12 pharmacy datasets.
Can a claims analysis be conducted to identify the potential savings opportunity?
Syrtis consultants are readily available to conduct a claims analysis and provide quantitative reports that outline savings potential.
