Tech-First Approach Ensures Savings Despite Shifting Legislation with Kathleen DePan

February 14, 2024 – accūrō Solutions
By Kathleen DePan, Edited by Allison Brekosky

In response to the dynamic nature of pricing methodologies, bill review companies must prioritize updating their established regulations and adhering to the latest legislative updates. At accūrō Solutions, our unique, tech-first approach empowers us to rapidly integrate new datasets and streamline rule adjustments. Our ARC bill review software was built to easily incorporate regulatory updates and pricing changes. This flexibility ensures our clients consistently reap the full benefit of their bill review savings; a process initiated by our data team’s comprehensive, predictive approach.

Recently, the Pennsylvania Commonwealth court in Federated Insurance Co. v. Summit Pharmacy, No. 115 C.D. 2023 (Pa. Commw. Ct. 01/02/24) concluded that the Average Wholesale Price (“AWP’) published by Red Book and used by the Workers’ Compensation Bureau (“the Bureau”) to resolve fee disputes are contrary to the legislative intent of the PA statute, as it was not in any way a measure of the actual AWP paid by pharmacies and wholesalers and was therefore invalid. The Commonwealth court has directed the Bureau to promptly identify and publish in its place a nationally recognized repricing schedule that accurately reflects the actual AWP of prescription drugs. At this time, the Bureau has not yet published a Red Book replacement.

While it’s speculative to predict the full effect of this change, in order to adhere to the legislative intent any nationally recognized schedule would likely be closer to the NADAC (National Average Drug Acquisition Cost) standard used by Federated Insurance Co. as a comparison than the Red Book AWP used by the Bureau. The pricing difference for the prescriptions in dispute calculated to an almost 98% savings. The potential cost savings of any change adopted by the Bureau that moves the standard closer to an actual AWP only serves to benefit Pennsylvania’s employees and employers. We have previously witnessed legal challenges to the manufacturer’s determination of average wholesale price in the bill review market. The ruling in Pennsylvania is important because it has challenged the use of this standard as a basis for reimbursement. In my opinion, this could eventually be indicative of larger-scale change.

At accūrō Solutions, we recognize the fluctuating nature of pricing updates, and our need to implement changes in a timely manner. Therefore, our ARC bill review software was built with adaptability in mind. The data and technology teams work hand-in-hand to research and then implement new fee structures as they are released. Our proprietary technology helps to ensure our clients consistently receive accurate bill review services, regardless of changing state-level requirements.

About the Author

Kathleen DePan currently serves as the Vice President of Regulatory Compliance and Data Development. With over 30 years of experience in the bill review industry, Kathleen has held numerous significant roles. She began her career at Options/NHR/Concentra where she managed medical billing to database design and analysis.

DePan was also a founding partner at Calculare Technologies, where she produced the proprietary bill review application for MCMC/York/Careworks. Later, she became the Manager of Data Services and Product Manager of both internal and external applications.

Learn more at https://accurosolutions.com/