Pharmacists and pharmacy benefit managers (PBMs) have increasing responsibilities as prescriptive rules and regulations keep changing. To be compliant, before they can focus on filling a prescription accurately, they must first resolve prescriptive authority by answering difficult questions such as:
- Is this provider authorized to write prescriptions?
- Where are they authorized?
- What are they authorized to prescribe?
Unfortunately, getting clear answers to those questions isn’t easy. The rules keep changing and increasingly complex layers of regulatory compliance are being added. For example, consider these recent changes:
- State boards across the U.S. have expanded the authority to write certain prescriptions to qualified, non-physician healthcare professionals like pharmacists and naturopaths.
- The Centers for Medicare and Medicaid Services (CMS) has mandated that all prescribers must complete an enrollment process for patient prescriptions to be covered by the Medicare Part D benefit. However, regulatory statutes prohibit some of the non-physician prescribers from enrolling in Medicare Part D.
- When attempting to validate OAP (other authorized provider) status, CMS recommends the use of taxonomy codes linked to National Provider Identifier (NPI) numbers. However, national codes don’t account for prescription authority varying from state to state.
If all of these and other changes aren’t confusing enough, the challenge of resolving prescriptive authority is further complicated by the need to complete the process in real time. Prescriptions must be turned around quickly to maintain profitability and an acceptable level of customer service.
While the challenges of today’s prescriber verification and authorization processes seem insurmountable, a solution does exist. Data-driven technology is the key to efficient pharmacy and PBM decisioning.
The right data partner has technology, fueled by relevant data sources, that makes completing the necessary research in real time a matter of just a few keystrokes.
Comprehensive data repositories aggregate, process and organize the latest provider records and include prescriber credentials, licensure, DEA and sanction data. And now, they also need to include NPIs, taxonomy codes and state-specific prescriber rules.
Finally, for pharmacists and PBMs to have confidence in the accuracy of the information, the quality of the data at the repository must be maintained. It is a continuous process that involves:
- Adding new data from pharmacy systems
- Matching, comparing and verifying new data against existing data
- Reconciling, cleansing and updating records appropriately
Ongoing data maintenance ensures that the data driving validations, verifications and authorizations is always as complete and current as possible. And with all that information available at one’s fingertips through a data technology partner, pharmacy and PBM decisioning is possible, and the safe filling of prescriptions can be done efficiently and in full compliance with all regulations.
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Want to know more? Check out our Provider Data MasterFile infographic, “Data—the greatest challenge and opportunity for healthcare.”