Leading drugstore chain chooses LexisNexis®

The customer is a major U.S. pharmacy chain that operates on a large scale, filling more than 5 billion retail prescription drugs at U.S. pharmacies in 2016. The pharmacy chain faces significant challenges in discerning the validity of prescriptions due to ongoing prescriber regulatory challenges, varying payer requirements, licensure inconsistencies, intricate drug diversion schemes, and stringent claims audits by the Centers for Medicare & Medicaid Services. These challenges make validating every prescription an operational risk, with potential consequences ranging from inappropriate reimbursement to tens of millions of dollars in fines for record-keeping, dispensing, and narcotics violations. The pharmacy chain requires a reliable solution that incorporates current information about prescribers and enables alignment with all relevant regulations to verify prescriber information prior to billing and dispensation. The pharmacy chain is also dealing with systems that were not designed for the complexity of today’s prescription claims process, resulting in a workflow that is not conducive to supporting pharmacists’ primary roles of patient service and safety.

Discerning the validity of prescriptions today is a complicated process made more complex by a number of factors, including ongoing prescriber regulatory challenges impacting daily pharmacy operations, varying payer requirements causing discrepancies, licensure inconsistencies across prescribers, intricate drug diversion schemes, and more stringent claims audits by the Centers for Medicare & Medicaid Services. Together, these issues make validating every prescription an operational challenge and risk, with consequences ranging from inappropriate reimbursement to tens of millions of dollars in fines for record-keeping, dispensing, and narcotics violations. The Drug Enforcement Administration (DEA) using their own federal data and data from state-level licensing boards to determine prescriptive authority is causing an even more complicated regulatory environment for retailers. Add to this the increased scrutiny from the media and others, and it is clear that retail pharmacies need a reliable solution—one that incorporates current information about prescribers and enables alignment with all relevant regulations in order to verify prescriber information prior to billing and dispensation. Unfortunately, many pharmacies are working with systems that were not designed for the complexity of today’s prescription claims process, often ingesting and matching data and technology components that are not designed to work together efficiently. The result is a workflow that is far from conducive to supporting pharmacists’ primary roles—patient service and safety.

To address this critical need, the major U.S. pharmacy chain chose VerifyRx™ from LexisNexis® Heath Care. In the retail setting, VerifyRx performs real-time prescriber verification checks before adjudication, reducing the risk of regulatory penalties due to preventable mistakes and overall compliance risk, and increasing the percentage of paid prescription claims. Through alignment with specific requirements and all relevant state and federal regulations, the solution also reduces time to dispense and helps prevent mistakes that could cause payments to be taken back or expose pharmacies and PBMs to further regulatory risk. Leveraging a powerful big data technology platform, VerifyRx processes millions of transactions a day with response times measured in milliseconds, enabling swift and effective identification of potential submission errors. Since the prescriber data is used by both leading retail pharmacies and leading PBMs, this correlation of information further reduces discrepancies that can stall efficiency. Among its other features and benefits, VerifyRx provides access to the timeliest data available, including real-time updates from the DEA and state data (when available), as compared to waiting for standard higher-latency delivery of batch files. It also offers instant audit defense, creating an audit trail through real-time logging, traceability to state and federal source data for each transaction, and monitoring and reporting of compliance performance. The solution is highly configurable to meet compliance, legal, and business needs with current data on state and federal prescriptive authority at the taxonomy and credential level. This includes federal and state sanctions data, DEA and state license status, grace-period allowance, and the ability to reject, warn, or capture responses by check. VerifyRx also includes over 60 checks, resulting from 7 years of feedback from users working to meet industry compliance challenges.

• A review of prescriptions presented to the large retail pharmacy chain in 2016 showed the system had prevented nearly 11.7 million irregularities uncovered in various categories, including DEA issues, NPI issues, sanctions, exclusions, deceased prescribers, XDEA issues, and state license issues.
• Beyond the numbers, the chain’s pharmacists were able to meet their dispensing responsibilities with greater efficiency and less stress, allowing them to focus on the patient’s needs.
• The company itself was better fortified against litigation and audits, and improved reimbursement rates bolstered the bottom line.
• VerifyRx allows corporate compliance to focus on compliance challenges, rather than on IT efforts and scheduling.
• The organization also reduced its compliance risk with automatic updates of changing laws and regulations, thereby playing a significant role in preventing fraud and abuse associated with prescription drugs.

• DEA issues, including prescriptive authority: 1,180,999
• NPI issues: 358,883
• Sanction, exclusions: 663,326
• Deceased: 26,279
• XDEA issues: 483,211