Case Study 3 – Drug Access Claims Resolution

Identifying the Issue
A pharmaceutical manufacturer with a physician-administered chemotherapy drug discovered that claims were being denied when the drug was billed for Medicaid patients in hospital outpatient units. The manufacturer asked DK Pierce to identify the cause of the denials and rectify the problem.

The Role of DK Pierce & Associates
DK Pierce maintains a comprehensive third party payer database that includes detailed information regarding claims processing in various settings of care. In order to determine the exact nature of the denials, we immediately accessed our database of hospital outpatient Medicaid information. Doing that allowed us to quickly determine that the drug was not included on a pharmacy drug coverage list (formulary), and therefore the hospital was precluded from billing the chemotherapy drug.

Demonstrated Outcomes
Utilizing our payer database, as well as our established relationships with various key Medicaid personnel, we were able to immediately understand the setting of care situation and contact the appropriate medical policy staff member to resolve the issue. DK Pierce not only notified the client regarding the cause of this issue, but worked with Medicaid to add the drug to the formulary the same day, ensuring patient access in the hospital outpatient treatment setting.