As the significance of drug manufacturer rebates is increasingly discussed across the healthcare industry, it’s important to understand why the complexity around rebate administration has led to certain issues and to identify the solutions available to protect this valuable cost-saving measure for providers.
Adjudication of prescription drug rebate claims is chief among those solutions in rebate administration, but the process isn’t something new. What is new, however, is the use of modern technology to aid in the adjudication process, augmenting the thorough audit of claims with automation and sophisticated processes that ensure transparency and compliance.
The Problem with Traditional Adjudication Processes
The rebate adjudication process is complex, involving multiple parties, including payers or PBMs, state entities, and eligible organizations (which include hospitals, specialty providers, pharmacies, and long-term care providers). Another level of complexity is baked into the process as different pharmaceutical companies that offer prescription drug rebates require claims data to be formatted according to their needs, which might differ from how other parties involved may gather and assemble their claims data. This has traditionally required a good deal of paperwork to ensure consistent formatting before submitting claims to ensure acceptance.
Pharmaceutical companies also perform their own adjudication process to ensure they aren’t paying out duplicate claims, but this process can take several months to complete before a rebate check is paid out to an eligible provider. There is no centralized system through which rebate claims can be submitted, adjudicated, and accepted.
One of the largest factors impacting the efficiency of adjudicating rebate claims is the lack of technology throughout the lifecycle of the submission, review, and issuance of a claim. Entities submitting claims are often been beholden to manual workflows that are prone to errors. Even when human error is mitigated, underperforming technology makes gathering the required data a time-consuming and complex task that still requires human oversight to ensure accuracy and completeness.
On top of the operational complexity involved in submitting drug rebate claims for healthcare providers, a changing regulatory landscape and legal action create further difficulties and uncertainty in the industry around the future of drug manufacturer rebates.
What is needed is a modern rebate management solution that creates as much transparency and compliance as possible to ensure drug manufacturers can trust the validity of claims they receive.
The Thirdwave Solution to Adjudicating Claims
At Thirdwave, we believe in the importance of ultimate transparency when helping healthcare providers achieve their lowest net cost. Part of this involves a concrete adjudication process that ensures claims are being submitted properly. This includes a thorough review to guarantee that required clinical data is included.
When drug manufacturers review claims data and identify discrepancies, claims are routinely denied. When duplicate claims are identified, both parties involved can miss out on potential savings and must work together to understand who is entitled to which rebates. In order to reduce the possibility of these denials, we place a great deal of importance on the adjudication process to ensure transparency and accuracy.
As a result of our in-depth adjudication process, manufacturers know that claims submitted by customers of Thirdwave are accurate and compliant. The knock-on effect of being consistently accurate is the positive impact it has on manufacturers and their willingness to continue paying out rebates to Thirdwave customers. In addition, we have spent several years building trusting relationships with manufacturers, which helps us protect these savings for our customers and others who submit accurate, compliant claims data.
A vital part of the adjudication process involves working with providers that are involved in the same patient’s care journey to confirm who is eligible to submit and receive prescription drug rebate claims. Transparency in this partnership is also vital to gathering the data required to submit a valid rebate claim.
To achieve this level of sophistication and transparency, the Thirdwave team includes healthcare industry experts who work in tandem with each provider’s financial and clinical staff to ensure a streamlined rebate submission process.
Behind our specialists is purpose-built technology—complete with powerful automation—that ensures consistency and accuracy in rebate claims that go far beyond the capabilities of a human-centered manual process.
With Thirdwave’s automation, we create a digital checklist of required data according to each drug manufacturer’s requirements and ensure claims data is valid before submitting. After the data has been collected, our proprietary technology adjudicates the claim to ensure no other party has submitted a claim for these rebates and that all the required data is properly formatted.
Once submitted, Thirdwave tracks the lifecycle of rebate claims with drug manufacturers and delivers rebate checks on a timely basis to our customers. With each claim, we guarantee the amount upon submission, taking any risk off the provider.
Thirdwave RX is a rebate administration solution that helps healthcare providers achieve their lowest net drug cost. Our team of healthcare, pharmacy, and financial professionals solve critical challenges in the healthcare ecosystem. With a proprietary technology stack and proven automation, Thirdwave offers the most innovative rebate product and services on the market.
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