Gain high value access and increase the profitability of your brands
From delivering dangerous treatments to billing for services not rendered, there are a host of reasons why a healthcare provider or entity could end up on federal and/or state Exclusion Lists. As we explained in our first and second posts, despite the existence of these lists, “bad actors” continue to deliver care and submit claims. In fact, an IQVIA analysis revealed a jaw-dropping $893 million in estimated drug expenditures in 2021 and 2022 from members on “bad actor” lists.
For pharmaceutical companies, this finding points to significant compliance risk. It suggests opportunities to tighten up commercial practices. And it opens the door to a much larger financial exposure: rebates paid to and through individuals and entities on Exclusion Lists.
Within many companies, there hasn't been a high level of awareness about Exclusion List exposure. As market conditions become more challenging, it’s critical that leaders from the C-suite to Market Access and Compliance teams become more aware of these risks.
Can you quantify your organization’s current exposure to Exclusion Lists? What steps are you taking to reduce that exposure? What are the benefits of adopting a more proactive, preventive approach over the long term?
If you don’t already have a clear understanding of your current exposure, consider performing a data-driven audit of your individual company. IQVIA’s Gross-to-Net team has experience with such audits. The process requires your company to provide IQVIA with rebate claims for the drugs to be analyzed. Our team then flags rebate claims where the fill date falls within an exclusion period and creates a summary of results by list category.
At the same time, consider incorporating an additional review of claims from deactivated NPIs, as well as those from Medicare opt-out HCPs, as measures to improve program integrity and reduce potential exposure to fraudulent activity.
A one-time audit is an excellent starting point, but not sufficient to reduce risk exposure over time. To that end, organizations need to invest in proactive monitoring of Exclusion Lists. This requires connecting data to help eliminate gaps where bad actors can create compliance risks and unintended consequences in contracting and rebating processes.
IQVIA experience points to three key advantages of a more proactive approach:
With a proactive, data-driven approach, your organization can avoid the risk of doing business with excluded healthcare providers and entities. IQVIA has a unique combination of data sources and expertise to help you connect all the dots — and support your compliance, program integrity, and contracting effectiveness goals.