Patient Driven Rx℠ forces health care providers to submit every claim for adjudication in all 100% copay situations.  Under cash discount programs, healthcare claims processors are able to diminish their typically high attrition rates and recoup previously lost revenue (20 – 50% for PBMs alone) caused by adjudication circumvention.  These solutions effectively transfer control of the claims submission decision from the health care provider to the consumer to prevent claim adjudication circumvention and preclude provider self-serving pricing.  

 

Those healthcare claims processors that don’t have an ability to prevent adjudication circumvention and inappropriate reversals in real-time can expect to be severely disadvantaged.  The MBRx solutions can be expected to change the terms on which healthcare claims processors and health plans can win and retain business by altering the acceptable expectations of their clients and the consumers they serve.  There is reason to believe the following question will become a minimum standard criterion in every Request for Proposal:  “Please explain the real-time, quality control measure that you [healthcare claim processor] can provide to prevent health care providers from circumventing the adjudication process and reversing claims without the patient’s or your [healthcare claims processor’s] consent or knowledge when the patient bears the full financial responsibility for the cost of the product or service”.  The Medical Banking Rx solutions generate a significant value proposition that enhances not only health plans and cash discount programs, but also employers’ and consumers’ perception of provided value and satisfaction. 

 

The MBRx solutions enable healthcare claims processors providing cash discount programs to effectively combat their typically high attrition rates and significantly increase their revenue by preventing claim adjudication circumvention.  For example, claim reversals under the pharmacy cash discount card programs of numerous PBMs are four to ten times that experienced under traditional, fully funded (cost-sharing) programs.  Again, since both HDHPs and CDHPs are essentially cash discount programs until deductibles are met, and approximately 90% of CDHPs and 50% of HDHPs do not meet their deductibles, the preceding applies to all such programs.