Specialty Drug Payment Integrity: 4 Key Attributes
- Specialty drug claims,which accounted for an estimated $243 billion in U.S. pharmaceutical revenue in 2023, are often complex and costly.
- A new white paper suggests that a multifaceted approach is needed to ensure payment integrity and accuracy in specialty pharmacy claims.
- The paper outlines four key strategies for improving the handling of specialty drug claims and maintaining claims payment integrity.
Tackle the complexities of specialty drug claims with a strategic approach. Our new white paper reveals four key attributes essential for bolstering specialty drug payment integrity and safeguarding against costly errors. With specialty drug spending soaring, it’s critical to address vulnerabilities like inaccurate coding, duplicate billing, fraud, and waste. Learn how a dedicated team, detailed claim reviews, and pre- and post-payment verification enhance accuracy. This piece outlines the critical steps to reduce costs. Discover how you can optimize processes and achieve greater financial stability within your healthcare plan. News Directory 3 is committed to providing you with the leading insights into the evolving landscape of healthcare payments.Discover what’s next to improve your company’s results.
Strategies to Improve Specialty Drug Claims Payment Integrity
Updated June 14,2025
Specialty drug claims,which accounted for an estimated $243 billion in U.S. pharmaceutical revenue in 2023, are often complex and costly. this complexity makes them susceptible to billing errors, fraud, waste and abuse (FWA). While prior authorization is a common verification method, it often lacks the sophistication needed to address the nuances of these claims.
A new white paper suggests that a multifaceted approach is needed to ensure payment integrity and accuracy in specialty pharmacy claims. Matthew Herbein, director of audit operations, co-authored the paper.
The paper outlines four key strategies for improving the handling of specialty drug claims and maintaining claims payment integrity.
- Dedicated Team: Establish a specialized team comprising pharmacy technicians, nurses, physicians, and data analysts. This diverse team can provide a comprehensive outlook on specialty drugs billed to both medical and pharmacy benefits.
- Focus on Details: Pay close attention to details such as the National Drug Code (NDC), quantity, and diagnosis codes. These elements frequently enough contain data errors that can be corrected.
- Multiple Reviews: Implement both pre-payment and post-payment reviews. This allows cross-referencing of pharmacy claims history with medical claims, providing additional verification layers.
- Closed-loop system: Connect post-payment claim review results to fraud, waste, and abuse (FWA) pattern detectors. This reduces duplication and enhances machine-learning driven insights and accuracy.
The white paper also highlights common errors found in specialty pharmacy claims, including inaccurate coding and duplicate billing. Addressing these issues can lead to significant improvements in payment accuracy.
What’s next
By implementing these strategies,healthcare plans can improve their payment integrity processes,reduce costs,and ensure accurate billing for specialty drug claims.