Student Dissertation

Agency : PBM; Pharmacy Claims; TAT; TPA; Health Insurance

Objective : To determine the percentage level of non-updated pharmacy license and its possible reasons and see its impact on pharmacy claims and suggests the possible ways to decrease the number of pharmacy claims rejection.

Background : Claim is the only reason the consumer (insured) buys an insurance product. Nowadays insurance companies hire TPAs for the claims settlement, but healthcare providers experience a substantial delay in the setting of their claims by TPAs, these delays may be due to certain reasons like non updation of pharmacy license or incomplete information in the online system. Pharmacy Benefit Management-PBM is software on which pharmaceutical requests have appeared and it handles the prescription drug benefit component of an individual’s health. It implies to Healthcare providers, payers and third-party administrators approved by DHPO to participate in the health insurance scheme and PBM service providers engaged by DHA/MOH/DOH licensed healthcare providers, payers or TPAs to provide PBM services.

Methodology : A descriptive study was conducted in Aafiya Medical Billing Services LLC, Dubai and the secondary data of 769 pharmacy providers along with PBM dimension list was taken. Prospective analysis of pharmacy claims was done, and the source of data was networking and claims department.

Findings : Out of 769 pharmacy providers, 200(26.1%) pharmacies were un-updated which impacted 65(32.5% of 200) PBM claims. The analysis states that 76.92% of cases were delayed due to un-update of regulatory license on AAFIYA portal which is maximum.

Recommendations : Claims will not get downloaded over the old license number which will lead to increased TAT of Pharmacy Claims. There may be a temporary suspension of services by the provider also payment may go too wrong provider.


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