Can You Answer These Questions About Your PSAO?
How do you handle Effective Rate Contracts?
Effective Rate contracts may generate variances from the point-of-sale reimbursement to the contracted rate. Our goal for the network is to manage reimbursements to the terms of the contract; meaning overpayments are collected and underpayments are paid out. It is important for our pharmacies to have an accounting of every claim that is processed under these arrangements and have full visibility to any financial implications over the term of the contract. Our solution — an intelligent, data-driven escrow process to manage out entire network of pharmacies.
For this process, we review near real-time claim level data from your pharmacy and escrow estimated variance amounts based upon the Ingredient Cost and Dispensing Fee paid at the point-of-sale to the rates in the contract. In the event that a pharmacy is net overpaid for their claims, a corresponding escrow amount is held in reserve to meet the contractual obligation. Net underpaid pharmacies are NOT assessed any escrow amount. This escrow process monitors ongoing claim activity throughout the contract year and continually adjusts escrow balances to correspond to the calculated estimates.
Periodically, Pharmacy First receives claim and aggregate level reporting from the PBM showing contract variance amounts. Our process imports this data and dynamically compares claim level variance estimates to actual amounts reported by the PBM. Any adjustments are made at this time, and validated amounts are accessible in our Member Portal.
At the end of the contract term, we complete a full review of the claim level data for the entire PSAO and dispute any claims not meeting the criteria of the contract terms. Each pharmacy receives a final accounting of every claim they processed, the point-of-sale reimbursement, and the variance amounts. At this time, Escrows are cleared for all net overpaid pharmacies to meet the financial obligation to the network, and net underpaid pharmacies receive their distribution of funds. All of this data-driven process is to ensure appropriate reimbursement across the network.
Do you provide the flexibility to opt-in/out of Preferred rate contracts?
Our flexible options extend past our services. Pharmacies now have the option to choose between a preferred or non-preferred agreement for the Blue Cross Blue Shield of North Carolina plan. Our dedicated Customer Service Team Members are available to help your pharmacy navigate this contract process.
Are you aligned with the values of my independent pharmacy?
Given that each pharmacy member is an independent business with different needs and goals, Pharmacy First evaluates contracts for their impact on the entire network. Our contracting approach is a balance of access, outcomes, and reimbursement (quality vs. quantity). This conservative contracting philosophy allows pharmacy owners to maintain long-term profitability and sustainability.
Pharmacy First recognizes the impact of performance-based networks on overall profitability. We offer a variety of clinical management platforms to give independent pharmacies tools to drive overall adherence and operationalize adherence-focused solutions.
Other PSAOs may be able to bury the true impact of performance-based networks within a purchasing contract or through socialization of the liability. Our data-driven process supports claim-level recoupments of overpaid point-of-sale funds applied to escrow accounts for our pharmacies. All of this is done within our industry-leading reconciliation platform that provides full transactional visibility to each claim.
Pharmacy First offers a flexible pharmacist-centric business platform with options instead of mandates. Compared to other PSAOs, our differences include:
- Central Pay or Non-Central Pay options
- Reconciliation with Central Pay or Direct Payments
- No purchasing mandates
- Consistent core PSAO service model with additional value-added service options
Our contracts cover thousands of plans and markets spanning across the country – but where other PSAOs prioritize contract quantity, we focus on contract quality. Our conservative approach means we will not accept terms that fail to protect your profitability or mitigate risk of DIR clawbacks. For every contracting decision, we balance access, outcomes and reimbursement to strengthen sustainability and serve you best.
As the first PSAO to achieve URAC accreditation as a Credentials Verification Organization, we provide comprehensive credentialing, complete with compliance training. Through our PFCares program, we rigorously verify credentials for not only the pharmacy, but all staff as required by our payer contracts. For you, that helps ensure organizational excellence that drives a higher performing network of pharmacies – and the benefits do not end there.
Every penny on every claim – that’s what you need as an independent pharmacy, and it’s precisely what we deliver. Through our industry-leading software and support, we do the work for you, including research and recovery for every cent owed on every unpaid or underpaid claim. Optional central pay provides rapid reimbursement through daily ACH deposits, or we offer convenient direct pay solutions with integrated data visibility into payment details.
We offer MAC appeals, cash claims management and rebate programs, quality and performance monitoring, online reporting, MTM platform support, and much more. It’s all part of our commitment to being your partner in excellence. Our full complement of solutions comes with flexibility and scalability so you can decide – and receive – exactly what you need for your unique business and competitive environment.