FAQ's
Pro Pharma is known not only for our data analytical expertise, but also our extensive use of acronyms! Therefore, we have included some most Frequently Asked Questions about a few of our key products below. If you have any questions that are NOT included on this page, please submit them to us on the Contact Us page.
- Can JCode pay my bills?
- NO, but it gives the user a method to pay for specialty injectables that is fair to the providers and saves money for the purchaser.
- What is the JCode Calculator™ and what can it do for us?
- It is a list of HCPCS and CPT code with the associated drug, by Brand name, generic name, NDC number, package quantity, unit value, and the pricing. It will allow you to pay your drug claims without doing a lot of outside research. You can search by any field and then find the unit price and apply it to your drug bill.
- How often are the prices updated in the JCode Calculator™?
- The prices are updated quarterly. Any NDC codes that have become invalid will be replaced with a valid code at that time. Also changes in the codes themselves are updated quarterly.
- How does the JCode come to us after we decide to make the purchase?
- The JCode Calculator™ is available 24-7 via the internet in a totally searchable format. You will also receive a copy in Microsoft Excel format by email. You can search this document as you would any other excel file. You can upload the file to your laptop for use when you are traveling or when the internet is unavailable. If you prefer to deal with hardcopy, the JCode Calculator™ arrives pre-formatted to print on legal size paper.
- If I have a question about a code or drug, how long will it take to get an answer?
- Whether submitted by phone or by email, all questions are answered within 48 hours on weekdays but usually faster.
- I found the HCPCS code that I need but the NDC in Pro Pharma's JCode Calculator™ isn't the same as the one on my invoice?
- The NDC listed in the JCode Calculator™ is the least expensive commonly available package from a reliable manufacturer who is NOT a repackager. That is the unit price you should be paying if you have to choose to pay the lowest price. If you choose to pay for a particular NDC, then look up the specific NDC for the price on the date of service.
- I have a bill for Code J7622 but I can't find that code listed in the JCode Calculator™?
- That is a code for a compounded drug. Compounded drug codes are not listed as we have no way to know what components are involved, so we can't price them.
Call Pro Pharma for assistance at (888)701-5438 - I have a bill for a brand new drug and it doesn't have the code listed. What should I do?
- Do a search by the description and use the generic name or search by Brand Name and see if it comes up as an NOC (Not Otherwise Classified) code e.g. J3490, J3590, J9999, etc. New drugs are frequently listed in that manner.
- What is Invoice Screening™ and what does it mean to my organization?
- Invoice Screening™ brings the purchasers' Accounts Payable function into the 21st Century by pre-payment auditing of PBM and Health Plan pharmacy invoices.
- What claim details are analyzed in the Invoice Screens?
- Among the claim details analyzed in the Invoice Screens are: eligibility status of the member, claim adherence to the defined benefit, data validity, and pricing compliance with contract guarantees.
- Which aspects of each claim are validated in the Invoice Screens and how is this validation completed?
- Coding of drugs is compared against reference databases to ensure obsolete identifiers and pricing parameters are not used. Physician and pharmacy identifiers are compared against national files to prevent fraud, waste, and abuse.
- How can the Invoice Screens help me identify opportunities to save on my plan's total drug spend?
- In addition to reporting claims which are priced in variance from any contractual agreement, the Invoice Screens identify claims which are eligible for various pharmacy chain generic discount programs. Invoice Screen reports also identify variances from the drug manufacturer's published pricing, FUL pricing, MAC pricing, and WAC/WAC*1.2 pricing. This information will identify areas where opportunities for savings exist.
- What aspects of each plan benefit are examined in the Invoice Screens?
- Each claim is tested for multiple factors which are defined by the benefit. Among the characteristics which are examined are: formulary compliance, adherence to quantity/days supply limits, early refill, prior authorization adherence, step therapy, and copayment verification.
- How can I ensure that I am only paying for eligible members and valid claims?
- Screen your invoices against your eligibility files and check all claims for valid information.
- How can I ensure that I am paying according to my pharmacy contracts?
- Re-price all claims against contract rates. Reject those claims that are paid above contract guaranteed fees.
- How do I know that my pharmacy network is being treated fairly?
- Check pricing for each major pharmacy to ensure that all brands and generics are priced the same way.
- What is a Quality Management Program?
- The Pro Pharma Quality Management Program™ changes the health care system for pharmacy benefits for self insured payers, from the inside by managing trend and utilization. The result is measurable improvement in quality, low single digit inflation, and a partnership with providers.
- As a Benefits Manager of a Self-Insured company, I see our drug trend increasing each year. Is there a solution to help my organization manage this expense?
- The solution is to manage utilization as well as cost. Utilization is the multiplier that is addressed by ensuring coordination of care, reducing polypharmacy and providing evidence-based solutions to prescribing.
- How do I manage pharmacy benefit drug trend?
- Pro Pharma has a Quality Management Program™ (QMP) which is a multi-faceted approach employing education, targeted data interventions and coaching to achieve long-term results.
- Is QMP just another disease management program?
- NO. The QMP targets all medical problems, because patients have generally more than one problem.
- Is QMP just a "one trick pony" solution for one year, and then the trend reverts to the mean?
- The QMP targets prescriber behavior change. When prescribing is evidence-based and simplified, change is sustainable.
- How can the QMP get doctors to comply when other programs have varied success?
- The QMP identifies the prescriber issues and aligns incentives to ensure that prescribing change is behavioral and therefore maintained. Pro Pharma offers positive reinforcement to sustain change as well as offering resources to assist w/ the change, such as a Preferred Client Prescribing Guide.
For more information please contact Carol Stern @ 818-701-5438
or carol.stern@propharmaconsultants.com
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