RJ Health Systems brings a focused, knowledgeable team of pharmacists and health care professionals to each consulting project. We can discuss your organization’s objectives and provide the data to make more informed policy decisions.
Our analysts review drug claims to identify appropriate utilization, accurate reimbursement, and help predict future revenues and expenditures for coded products. We also perform drug and medical claim reviews that analyze drug therapy and diagnosis, compare individual provider utilization to benchmarks, and evaluate for under- or overutilization of products and services.
Health Plans
RJ Health Systems helps organizations effectively and efficiently manage pharmaceutical care through the custom development of programs and reporting. Our clinical staff develops health plan-specific procedures that help clients find the balance between member/provider satisfaction and prudent fiscal management.
We work with clients to establish and maintain benefit designs that provide appropriate care and lower overall costs. Our analysts work to develop and manage formularies, perform step therapy edits, and conduct prior approval management and data analysis reporting. We also perform drug utilization reviews to determine whether more clinically sound and cost-effective treatment may be available.
Services
- Formulary Development, Implementation and Management
- Pharmacy & Therapeutics Committee Development and Participation
- Development of Step Therapy Protocols
- Patient Drug Utilization Review
- Prior Authorization Process Management
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Data Analysis Services
Customer Service Call Center Operations
RJ Health Systems works with the client, as well as their Pharmacy & Therapeutics Committee, to compile and analyze a list of drugs for inclusion in a health plan formulary. We approach the formulary development process with balanced consideration for clinical efficacy as well as drug cost. Our team also considers the unique business drivers of each client’s organization.
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We develop and manage formularies in accordance with medical necessity and medical appropriateness as defined by benefit guidelines. Formulary management includes processes for exception procedures for coverage of non-formulary drugs under specific circumstances. Working directly with the client or the Pharmacy Benefit Manager, RJ Health Systems analyzes the clinical attributes as well as the cost of comparable products in the same drug classes or categories for inclusion in a formulary.
A Pharmacy and Therapeutics Committee is an essential component of an effective pharmacy management program. A P & T Committee provides a system of checks and balances to ensure that coverage policies, formulary decisions and management programs are appropriate and will accomplish the goals of the health plan.
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Based on our diverse experience in the health care industry, RJ Health Systems understands all of the factors that go into developing a constructive committee. We can assist health insurance providers, managed care organizations and other clients, or work independently to develop a Pharmacy and Therapeutics Committee. Depending on the needs of the health plan, RJ Health Systems’ responsibilities can range from chairing the committee to serving as an active participant.
RJ Health Systems develops step therapy protocols based on sound clinical evidence that identifies a drug’s appropriate place in therapy. We work with our clients to control costs and mitigate risks associated with the drug therapy. Our analysts submit recommendations for step therapy protocols to the Pharmacy and Therapeutics Committee for review and final approval before they are implemented.
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We also develop electronic step edits in conjunction with the prescription drug claims processor. This allows for point-of-sale messaging to ensure protocols are being followed. As new drugs enter the marketplace, we identify the safest and most cost-effective treatment. We develop processes for educating providers to further enhance protocol compliance.
RJ Health Systems uses a multi-faceted approach in conducting our patient drug utilization review programs, with joint goals of improving patient care and eliminating unnecessary costs. We develop criteria for identification of potentially inappropriate drug utilization patterns and put them in place to identify cases where further review should be conducted.
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In addition, our clinicians conduct reviews to identify disease state/drug class appropriateness, proper dosing/utilization, generic substitution opportunities and drug interactions. In conjunction with the health plan, we develop communication protocols to notify prescribers of findings of the patient drug utilization review. In keeping with best practices, we conduct continual monitoring to assess if corrective action has occurred.
Our analysts tailor the prior authorization process to the needs of our client and the goals of the individual health plan. Our work is guided by the latest input from medical specialists, professionals, and clinical literature from respected medical journals and other professional sources.
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If necessary, RJ Health Systems seeks information pertaining to new drugs and devices from the manufacturer. We develop process management criteria based on nationally recognized guidelines and evidence-based medical studies. The end result is an effortless, automated system so providers can easily access information on drugs requiring prior authorization and the approval process.
RJ Health Systems offers data analysis, including retrospective review of paid claims, trend reports and benchmarking, on a scheduled or ad hoc basis. We work with the health plan to identify opportunities for cost savings, more efficient processes, and other modifications. Our analysts can accommodate client-specific reporting requirements.
Our dedicated, service-oriented team provides patients, providers, pharmaceutical/device manufacturers, and health plans with customer call center operations. The functions we offer can range from an informational call center to an interactive center that implements health plan-specific policies/procedures such as prior authorization and step therapy protocols.
Pharmaceutical/Device Manufacturers
Our work developing and distributing drug and device-specific information to target audiences increases product awareness, highlights clinical attributes and clarifies any applicable HCPCS and CPT® coding guidelines. Once approved, we can distribute the advisories to specific client lists or to our exhaustive client database.
Our consultants work with drug and device manufacturers to secure HCPCS/CPT® codes for their products or related services, which will facilitate provider coding and reimbursement. In addition, our Compendia submissions support the clinical case for a drug's alternate uses.
Services
- Drug/Device Coding and Reimbursement Advisories
- HCPCS/CPT® Code Requests
- Reimbursement Formulary Guides
- - Reimbursement/Clinical Hot Line numbers
- - Package Insert
- - How to Bill information
- - Sample CMS 1500 and Hospital UB-04 claim forms
- - Related HCPCS, ICD-9-CM and CPT® Code Information
- - Frequently Asked Questions
Compendia Submissions
Survey Services
Call Center Operations
Drug coding and reimbursement advisories from RJ Health Systems are designed to provide essential information to payors and providers regarding how to bill and code for a particular drug/device. This service can help raise awareness of an emerging drug or device and remove confusion around billing that could prevent some physicians’ offices and other providers from administering it.
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The two-page document that we develop provides appropriate drug/device billing code(s), related administration and ICD-9-CM codes, detailed billing instructions and a sample claim form to assist in the billing/reimbursement process. We offer distribution options that range from a select audience list to a more broad distribution.
RJ Health Systems consults on and prepares the submission of requests for the creation of HCPCS/CPT® drug/device/service codes. A specific HCPCS/CPT® code for a product/service will streamline the reimbursement process for both providers and payors, which increases the likelihood of correct reimbursement and faster processing of claims.
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Our services range from development and submission to assuming the lead/primary contact role in the application process. RJ Health Systems works closely with the manufacturer to ensure that all timelines and benchmarks are met, enhancing the likelihood of success.
RJ Health Systems can also assist with the submission of requests for the creation of an S-Code for the Blue Cross Blue Shield Association.
These multi-page guides provide detailed clinical and billing information for a drug/device and are intended for distribution to payors and other select audiences. RJ Health Systems customizes the guide to client specifications and target audiences.
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Guides can include information such as:
Many organizations use Compendia listings to develop coverage policies for a particular product, including off-label use of a drug. RJ Health Systems can assist or take the lead role in submitting drug-related information to the various Compendia. We work closely with our clients to be certain that the necessary studies and supporting documentation are included in the submission, and we follow up on the submission process.
RJ Health Systems provides survey services, including the design, development, distribution, collection and tabulation of results. We provide information in aggregate to allow the manufacturer to make informed decisions regarding potential product purchases, marketing strategies, and sales opportunities.
RJ Health Systems staffs a dedicated call center to answer questions related to our clients’ pharmaceutical drugs/devices, reimbursement, coding and other inquiries. We regularly field calls from patients, providers, hospitals, managed care organizations and others. Our professional staff can act as an informational call center or an interactive center, depending on the needs of the client.
CPT® copyright 2010 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.
