Health Plans face a structural challenge: recovering payments when primary coverage information is not presented at the time services are rendered. For many reasons, recipients often do not share other coverage information or are unaware that other coverage exists.
Without technology to prospectively identify that coverage at the point of service, Health Plans must accept claims and rely on manual pay-and-chase processes to retrospectively identify and pursue primary payers for reimbursement. These traditional recovery approaches are inefficient and expensive, and they produce recovery rates of less than 17% of the dollars billed to primary payers. The fundamental constraint is data availability at the time of claims payment. No amount of workflow optimization overcomes the structural latency that prevents access to current commercial coverage when claims are adjudicated.
ProTPL, a real-time point-of-sale cost avoidance service, was developed by Syrtis Solutions to prevent improper claims payments rather than chase them after the fact. The company’s founders, industry veterans with experience in pharmacy claims processing and claimant recovery, recognized that the market needed a technology-based solution that identifies other coverage before payment occurs.
ProTPL accesses the nation’s largest master patient index (MPI), representing over 300 million covered individuals nationwide, using industry-standard transactions at the point of sale. The program has identified that between 6% and 14% of all claims submitted under Health Plans have other pharmacy coverage.
Integrating ProTPL delivers real-time identification of claims that have other coverage. These claims can be cost avoided, along with all future claims for that memeber, which effectively eliminates the post-payment recovery process.
ProTPL supplements rather than replaces the coverage already in your files, carrier feeds, and batch matching processes. It closes the specific gaps those systems structurally cannot, identifying unknown coverage on the day claims are processed. Because verification operates independently of core claims processing, a file interruption does not prevent claims payment; claims continue through existing workflows, keeping member access and provider payment continuity unaffected.
Syrtis’ proprietary software processes transactions in sub-seconds through standard pharmacy transaction sets and integrates seamlessly into any pharmacy program. ProTPL eliminates disruption for the provider and patient at the point of sale, improving patient care and service.
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 program. ProTPL eliminates disruption for the provider and patient at the point of sale improving patient care and service.
ProTPL can be customized to each payer’s unique needs. The daily claims file is automatically routed to the Syrtis OHI discovery platform, which queries the nation’s largest master patient index. When other coverage is found, the system returns the corresponding coverage information for the customer to use for future cost avoidance.
A simple daily exchange of secure files solves the pay-and-chase problem without disrupting your current processes or existing vendor contracts.
Every night, your IT generates a standard format file of pharmacy claims that is sent to Syrtis Solutions via secure FTP.
Syrtis Solutions receives your claims file and initiates our ProTPL solution by reaching out to our data partners.
Syrtis Solutions discovers the latest Rx OHI data and returns the responses to you in a standard format.
Syrtis Solutions discovers the latest medical OHI data and returns the responses to you in a standard format. (Syrtis Solutions only checks for medical OHI on those members you indicate do not have current active medical coverage on file.)
The responses are used to cost avoid all future claims, reverse claims made in error and to make updates to your eligibility and adjudication systems.
1601 Rio Grande, Suite 330, Austin, TX 78701
Phone: 866-960-9358
Email: info@syrtissolutions.com
