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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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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 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.

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