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Specialty Drugs: Ensuring payment accuracy beyond prior authorizations

While many plans lean on prior authorizations to ease the processing of specialty drug claims, our experts explore more comprehensive options for getting claims paid more accurately—and more quickly.

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Almost half of specialty drug claims occur under the medical benefit of a plan rather than the pharmacy benefit. Specialty drugs are typically administered by the provider—often intravenously—and are used for treating chronic and complex diseases. They are also notoriously expensive.

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 outlines best practices for handling specialty drug claims in a way that goes beyond prior authorization, for better accuracy and faster payment.

About the Author

As a senior consultant, Jonathan supports Cotiviti’s vast library of Drugs and Biologicals payment policies and aids in presenting these policies to clients. He fills the important role of bridging the gap between client teams and researchers developing Cotiviti’s D&B policies. Jonathan has also managed and operated Cotiviti’s pharmacy fraud, waste, and abuse product since 2016. Prior to joining the D&B team, he worked as a retail pharmacy manager for over 12 years and has been a licensed pharmacist for 13 years.

Profile Photo of Jonathan Starr