Pharmacy Advantage Service

Medidal’s Pharmacy Reimbursement Eligibility product can find reimbursement on self-pay pharmacy accounts. We conduct searches for Medicare Part D and Medicaid eligibility and, once accounts are identified, we submit the claims as part of the included service. Medidal has developed proprietary algorithms that automate the bucketing of data received from the facility, Medicare and Medicaid. This allows for prioritization of claims for further discrete processing, including denial management.

Integration with hospital systems is not necessary in order to perform our pharmacy eligibility service via batch. Medidal provides data requirements to assist in automated file creation, reducing the need for manual ETL processes on the facility’s side. Access to Medidal’s secure file transfer is then provided to the facility for file dropoff, and claims processing and adjudication is completed within 48-hours of file receipt (but typically within the first 24-hours).


A "Safety Net" for Safety-Net Hospitals

When a facility’s pharmacy dispenses drugs irrespective of payment at time of service (as at a Safety-Net Facility) the ability to find Medicare Part D or Medicaid coverage later becomes more difficult. Most pharmacy systems are not equipped to perform these complex searches after the fact. In the case study below, at one Safety Net Hospital utilizing Medidal's service we found:

  • 19% of the individual claims were eligible for Medicaid
  • 27% of these claims were successfully reimbursed through our Pharmacy Eligibility service
  • Total recovered amount for the facility: over $250mil reimbursed for a single-year review

    Case Study