Pharmacy Benefit Management
Our clinical pharmacy utilization reviews aim to enhance treatment efficacy, improve patient outcomes, and manage healthcare costs. Through comprehensive analysis and evidence-based evaluations, we assist PBMs in developing targeted cost-containment strategies while ensuring high standards of care.
medlitix’s utilization reviews help improve the quality of care and empower PBMs to navigate the complexities of pharmaceutical benefits with confidence. We deliver actionable recommendations that balance clinical effectiveness with financial sustainability, ensuring that patients receive the right medication at the right time.
Through our expertise, PBMs can proactively address emerging trends, regulatory requirements, and market dynamics, fostering a more efficient and patient-centered healthcare ecosystem. Our commitment to continuous improvement drives better health outcomes while controlling costs and enhancing the overall member experience.
Non-Formulary Exception Reviews
Determining whether a non-formulary drug is medically necessary based on available alternative treatments.
DRG Validation Reviews
Ensure claims are accurately coded and billed under the MS-DRG system. medlitix reviews medical records to verify that diagnoses, procedures, and DRG assignments align with documentation and coding guidelines.
Key Points:
- Purpose: Prevent overpayments, underpayments, and billing errors.
- Process: Reviews of medical records for coding accuracy and clinical validity.
- Impact: Appropriate utilization of drugs.
Common DRG Errors:
- Upcoding: Assigning a higher-paying DRG without sufficient documentation.
- Clinical validation issues: Diagnoses like sepsis or respiratory failure not fully supported.
- Incorrect principal diagnosis selection: Choosing a condition that does not align with treatment.
- Missing complications or comorbidities (CC/MCC): Overlooking secondary conditions that impact DRG assignment.