As new specialty drug treatments emerge, there is a growing focus on managing complex therapies and cost containment strategies within medical and pharmacy benefit plans. This blog post outlines what are J-Codes, audit process and benefits of performing a J-Code analysis.

What are J-Codes?
J-Codes are part of the Healthcare Common Procedure Coding System (HCPCS) Level II set of procedure codes. The codes are used by Medicare and other managed care organizations to identify injectable drugs that ordinarily cannot be self-administered, chemotherapy drugs, and some orally administered drugs.

Related: What are J-Codes?

Audit Process

The J-Code process begins with loading claims data within the following delivery silos:

  • The medical benefit
  • The retail pharmacy network
  • The PBM’s Mail Order or Specialty Program

Placing claims in these delivery silos allows for more efficient price comparison. The comparison validates best-price analysis and that claims were properly integrated. Next, claims data is benchmarked and reviewed to determine whether a medical and pharmacy benefit was being provided simultaneously.

Related: 4 Financial Benefits to Having a PBM Audit

Benefits of Performing a J-Code Analysis

We look for opportunities for site of care delivery and potential for rebate dollars. These financial opportunities may be due to claim movement to a more cost-effective delivery silo or assisting with leverage to gain more rebate share within the medical benefit.

One area we routinely find reimbursement dollars for the plan or our client’s, is when we uncover “double-dipping.” Double-dipping is a wasteful practice that allows a subscriber or provider on either side of the delivery chain to both be paid simultaneously. Costs associated with double-dipping can have a highly negative effect on your bottom line and future healthcare spend.

For more information about J-Code Analysis or would like a proposal, please contact [email protected]. We look forward to talking with you!