Utilizing NDCs for Medical Benefit Drugs – A Payor’s Perspective

RJ Health Systems’ most recent April 27th Specialty Pharmacy Webinar “Utilizing NDCs for Medical Benefit Drugs – A Payor’s Perspective” focused on improving drug data capture on Medical Drug Claims. The webinar described the limitations of the HCPCS model and the value of alternatively using the FDA assigned NDC for drug billing purposes. The webinar attendees completed a short survey, as part of their registration. We have complied the survey responses and are sharing their insightful feedback below. The survey results consisted of 273 registrants across 114 different Health Plans. There were multiple attendees representing the same Health Plan. So, as you might expect, there were some conflicting answers within the health plan attendees.
Looking at the first question, we can see that there is a large number (59%) of registrants saying their health plans currently require NDCs for medical drug claims, with 12% planning to implement the requirement soon.
For those that require NDCs, 39% of the registrants said they validate that HCPCS to NDC unit conversions, with an additional 10% planning to implement unit conversion validation. There were 24% stating they had no plans to implement unit conversion validation.
Similarly, for those requiring NDCs, they were asked if they formally pend or deny the claims due to inaccurate or missing claim NDC details. This becomes the true test for a health plan to whether or not they are driving to an absolute, exact NDC and conversion match. Applying this level of editing and rejection control can change or temporarily disrupt entire claim systems when implemented. But without enforcement, consistent and accurate NDC detail can’t be achieved. The responses indicate that 45% of those requiring NDCs are in fact pending or denying the claims in order to get corrections and resubmissions that will pass the edit criteria.
Finally, we wanted to understand how the plans were implementing and managing these capabilities using either internal or external resources. For those requiring NDCs, 31% of the registrants said they use health plan systems, with 10% using external vendors and 26% didn’t know how it was being performed.
The HCPCS to NDC crosswalk and unit conversions available from ReimbursementCodes are a timely and reliable source for health plans to internally validate NDCs and unit conversions on provider medical drug claims. Additionally, the new RC Claim Assist tool from RJ Health Systems can further support your NDC capture program by making it available to your network providers for easy lookup and validation of NDC data at the time of claim entry and prior to submission.  The combination of these services can effectively support the entry- to-adjudication process necessary for capturing the accurate NDC drug data required for manufacturer rebates and insightful clinical and utilization analyses. If you’d like to view the slides or the recording of the entire “Utilizing NDCs for Medical Benefit Drugs – A Payor’s Perspective” webinar, or if you’d like to learn more about our NDC Quality Solution, please emailinfo@rjhealthsystems.com
Source: RJ Health Systems – NDC Webinar Registration Survey, April 2016