Specialty drugs are complex. Managed by both medical and pharmaceutical benefits, specialty drugs are typically injectable drugs administered by a provider and are used to treat chronic diseases. They are also notoriously expensive, with U.S. prescription dispensing revenues from specialty pharmaceuticals estimated at $243 billion in 2023.

Their complexity and expense make specialty drug claims especially prone to inaccurate billing, or worse, fraud and abuse. While many plans use prior authorization to handle these claims, relying solely on this process can result in limited details that can leave plans open to inappropriate claims in their payment integrity process.

In this white paper, Jonathan Starr, PharmD and Matthew Herbein outline best practices for handling specialty drug claims for better accuracy and faster payment. Read to learn:

• How to improve payment integrity efforts within specialty drug claims
• Common concerns that can result from overrelying on prior authorization
• Fraud, waste, and abuse cases within specialty drugs

About the authors

	Jonathan Starr, PharmD Director, Content Solutions Jonathan directs a team of pharmacy specialists in developing new content related to pharmacy claims. He also supports Cotiviti’s vast library of Drugs and Biological payment policies and aids in presenting these policies to clients.
	Matthew Herbein Vice President, Audit Operations Matthew is responsible for managing and overseeing all pharmaceutical audit activities including overpayment recoveries, contract commitments, and customer satisfaction measure scores.