With Over 12 Million Claims Analyzed, EagleForce Health and ConnectiveRx Lead the Industry in Real-Time Insurance Verification

Managed Care Weekly Digest

By a News Reporter-Staff News Editor at Managed Care Weekly Digest -- EagleForce Health, LLC and ConnectiveRx announce the screening of more than 12 million pharmacy transactions since mid-year 2015 in support of the federal Anti-Kickback Statute (AKS) restricting the use of pharmaceutical manufacturer co-pay benefits to all government health plan members. In the past, the industry's screening for government beneficiaries relied on one or more of several plan identifiers listed on the patient's insurance card. Unfortunately, with the expansion of the Affordable Care Act and other coverages, many of the identifiers for commercial insurance and government insurance plans, such as Pharmacy Control Number (PCN) and Bank Identification Numbers (BIN) are commingled and non-distinguishable, thus making this methodology inadequate or inaccurate to screen for government beneficiary status (see also Insurance Companies).

EagleForce Health teamed up with ConnectiveRx to develop real-time insurance verification capabilities specific to government beneficiary eligibility for co-pay programs. "Our goal was to develop a solution to help pharmaceutical manufacturers further their compliance with the federal Anti-Kickback Statute," said Chris Dowd, EVP Market Development at ConnectiveRx. The AKS stipulates that with each pharmacy drug claim where a person is covered by a government health plan and benefits are paid by the government, the use of pharmaceutical co-pay cards or patient savings cards is not permitted. "We are very pleased to provide this unique and innovative capability to our clients and the industry allowing them to provide valuable co-pay assistance to their patients in the most practical and compliant way available," says Dowd.

To solve the problem, the industry had to look outside of healthcare to leverage more advanced evidence-based technologies and methodologies. The CEO and chairman of EagleForce Health, Stanley Campbell has provided cutting-edge knowledge and analytics to the defense and intelligence sectors for many years. Today, EagleForce Health is applying its neural computing, machine learning and artificial intelligence methodologies to provide real-time insurance verification that enables drug makers to more accurately identify patients who are using government-paid insurance, preventing them from illegally receiving co-pay program benefits. Most importantly, these advanced analytics capabilities allow for the identification of the vast majority of government health plan members including Medicare, Medicaid, Veterans Health Services, DoD, Indian Affairs, Bureau of Prisons, CHIP and more. In line with the intent of AKS, this service is not just focused on Medicare Part D.

"In this era of compliance, we believe our solution will be able to accurately identify between 5% - 20% of claimants which could otherwise improperly receive pharmaceutical copayment benefits without the integration of the EagleForce solution," states LtGEN (Ret) John Morgan, COO of EagleForce Health.

EagleForce Health and ConnectiveRx are rapidly expanding the use of this solution across many of the top pharmaceutical manufacturers that offer co-pay support to help patients obtain and adhere to the medications that they need. Tom O'Grady, senior legal consultant to Big Pharma further suggests that "Executives and legal regulatory departments within the industry are adopting this real-time eligibility solution so they can rest well at night knowing that they have deployed the very best government-beneficiary screening available."