Medical Drug Management Service™

The change adds up to savings Argus Health Systems understands the challenge of deciphering high-cost medical claims. With 25 years of experience on our side we can provide actionable information you need to control special medical costs, resulting in quality outcomes and savings where it counts. Medical Drug Management Service™ (MDMS) is a customizable, rules-based product designed to clinically edit and price medical drug claims that helps your organization become more efficient, and supports your initiatives with the same precision you can perform on the pharmacy side of the business for medical claims. Let the experience of the Argus team change the way you evaluate medical drug claims Applies the precision of our proven pharmacy claim management techniques to medical drug claims. Totally customizable clinical and pricing rules for drugs with HCPCS (Healthcare Common Procedure Coding System) Level II codes. Automatically identifies appropriate intervention opportunities.

Let MDMS™ help manage your medical drug spend and improve your bottom line

• Approximately four percent of health plan membership accounts for $78 billion dollars in specialty/biotech drug spend.
• Management and evaluation of medical drug claim data is difficult with current systems because of the inability to control drug-specific editing and pricing with HCPCS (Healthcare Common Procedure Coding System) Level II codes. Identification of claims submitted with an inaccurate relationship between the drug and the diseases the provider state are being treated, will improve your reporting of medical appropriateness.
• With 600-800 drugs in the specialty/biotech drug pipeline, utilization and spend are projected to increase, requiring tighter control and management.

While not all-inclusive specialty/biotech drugs can be defined as: Infused, Injected; Cost more than $1500.00 per month; Cost more than $5000.00 per treatment; Require special care or handling; Administered in a hospital, clinical, or patient home; May be covered by the pharmacy benefit; and May be covered by the medical benefit. These examples showcase the confusion surrounding the industry when attempting to build benefits, manage medical drug claims, and provide the best care possible for the member.

All of our tables relate the drug to FDA approved indications which represent what the FDA has approved at the release of the drug and is updated as new updated indications are added on a monthly basis.

Greater scrutiny of medical drug claims for accuracy and proper payment by state and federal agencies is on the horizon. The errors found by regulatory agencies often result in the health plan returning significant dollars due to overpayment. Common errors noted include: Reasonable units; Relationship between the drug (HCPCS) and ICD-9 submitted on the claim; Correct Pricing of the claim according to submitted units; Drug is appropriate for Gender; and Drug is appropriate for patient's age.