Medical Benefit Drug Management

Drugs covered under the medical benefit, including specialty drugs, present significant cost management and compliance challenges for health plans. Up to 30% of these claims are processed or paid inaccurately, and CMS estimates 8-11% of total reimbursement is wasteful. Unlike drugs managed under the pharmacy benefit, drugs managed under the medical benefit often lack visibility, making it difficult to control costs.

Argus offers a comprehensive solution for drugs covered under the medical benefit.   With our solution, health plans can identify new opportunities to improve quality of care and reduce revenue loss through editing and repricing the claim, site of care management, and medical rebates.

Edit and reprice capabilities

Our rules engine helps identify and resolve incorrect claim submissions by applying the health plan’s medical policy and provider fee schedule. We use the industry standard medical claim format to integrate with the plan’s existing claims processing workflow.

Site of care management

Our solution focuses on key therapies shown to have the greatest potential for clinical and financial outcome improvement. We leverage our specialty pharmacy using dedicated clinicians to assess and redirect members to lower cost site of care.

Rebate services

Health plans have the option to utilize Argus medical rebate contracts to improve revenue cycle management.  We also support plans with their own contracts to report and submit eligible claims for rebates using the medical NCPDP format.