Medical and Pharmacy Rebates:
In-Patient Health SystemsSPS Health qualifies eligible unmanaged In-Patient Pharmacy and Outpatient Medical claims for rebates on behalf of customers by collecting, processing, and submitting claims for formulary management rebate dollars. Our technology-driven and customized approach maximizes these untapped rebate dollars, driving revenue back to the health system and patients.
SPS Health works with hospitals and health systems to ensure that claims submitted are rebate eligible so that rebates are a sustainable new earnings stream, including:
- Validating that hospitals are at risk for the claims and ensuring that a health plan or PBM is not already accessing rebates on the claims
- Excluding 340b claims
- Auditing medical policies to comply with manufacturer requirements for paying rebates (typically on specialty infusion drugs)
Our program enables hospitals to access two types of rebates where the hospital can capture untapped claim dollars:
Pharmacy Rebates
For pharmacy benefits (e.g., diabetes meds, anticoagulants), SPS Health can help hospitals maximize rebates available by aggregating all eligible claims or capturing additional value by implementing clinically appropriate preferred drug lists.
Medical Rebates
For medical benefits (e.g., infused specialty drugs), SPS Health can help hospitals maximize available rebates through SPS Health-developed policies or custom formularies for specific drug categories to evolve medical policies for drug categories where more value may be available.
How It Works
Initial Process:
- Health system provides SPS Health with its pharmacy/ medical claims and current medical policies
- SPS Health identifies the claims where the health system is at risk (e.g., Part A)
- SPS Health estimates immediate value available based on current pharmacy/medical utilization through our rebate program
- SPS Health begins receiving monthly data feed for pharmacy/medical utilization
- SPS Health provides pharmacy rebate payments directly to clients
- SPS Health provides transparent reporting and quarterly business reviews with Client Services team to review the last 90 days of rebate impacts
- SPS conducts strategic reviews to ensure health system is dispensing in alignment with existing medical policies (where applicable)
- Value add and rebate opportunities grow as medical policies are updated in line with manufacturer standards
How It Works
Initial Process:
- Health system provides SPS Health with its pharmacy/ medical claims and current medical policies
- SPS Health identifies the claims where the health system is at risk (e.g., Part A)
- SPS Health estimates immediate value available based on current pharmacy/medical utilization through our rebate program
- SPS Health begins receiving monthly data feed for pharmacy/medical utilization
- SPS Health provides pharmacy rebate payments directly to clients
- SPS Health provides transparent reporting and quarterly business reviews with Client Services team to review the last 90 days of rebate impacts
- SPS conducts strategic reviews to ensure health system is dispensing in alignment with existing medical policies (where applicable)
- Value add and rebate opportunities grow as medical policies are updated in line with manufacturer standards