…David Donn, Chief Executive Officer of managed care advisory firm Donn & Co., said that while some recent progress has been made in pharmacy-benefit manager pricing transparency, that hasn’t been the case for most PBMs or for bill review, preferred provider organizations and utilization review companies.
“I’d say transparency, in general, is still given lip service and only discussed if brought up, and only addressed if pressed on by the client,” Donn said. “It’s a discussion not only worth having but worth fixing.” A client can help prevent overuse of UR by having clearly defined referral criteria for claims examiners, said Donn. He said overuse of utilization review is more common when the TPA offers UR services in a bundled arrangement.
A per-bill flat rate is one way to simplify payment for bill review services, Donn said. On the other hand, he said, “pegging the service providers’ fees to performance can help to hold them accountable.” The key is to have a clear definition of what constitutes bill review savings…