A Closer Look at: PPE – What are Pre and Post Edits (PPE)?
July 1, 2023
You may have heard the term PPE or read about Pre/Post edit programs before, but unless you have utilized one it isn’t obvious exactly how they work and what benefit they provide to the pharmacy. This quick overview will help explain the basics of Pre and Post Edit (PPE) solutions.
What is PPE?
Pharmacy Pre and Post edits solutions monitor the claims adjudication process to validate each claim and help ensure that prescription orders are submitted appropriately. PPE solutions improve accuracy by reducing claims submission errors, which helps decrease audit risk, drives productivity, and helps ensure maximum reimbursement.
Pre Edits
Pre Edits are used in real time at the point of claim adjudication, before a prescription is filled, and they check each prescription for errors, such as incorrect quantities or days supply, and missing or incorrect codes such as DAW, SCC, etc. The system will flag any potential issues, and provide pharmacy staff with actionable messages so that they have the opportunity to make informed decisions before dispensing the medication. Some PPE programs can even create rules at the pharmacy’s direction to automate the population of certain fields in specific scenarios to ensure proper adjudication.
Post Edits
Post Edits are used after the prescription has been filled, and they are primarily focused on monitoring and validating the claim response data received from the 3rd party payor. They help to ensure that the claim was processed and reimbursed appropriately. Common issues identified by Post Edits include claims being reimbursed at U&C or a MAC rate.
Reporting
Reporting is the third key element to a PPE solution. Reports should provide insights into issues identified by both the Pre and Post Edits, and are actionable in terms of identifying additional opportunities, and should also serve as oversight tools to monitor PPE program activity and also staff responses and interventions in the claims adjudication process.
Pre and Post Edits are available from numerous providers with varying degrees of sophistication. Some are integrated into certain pharmacy information systems while others are available as stand-alone programs. Some offer a very limited number of edits and limited reporting, while others are more robust and employ a more complex program logic with hundreds of edits and reporting that is intuitive, graphical, and user friendly. If you are considering adopting the use of Pre and Post Edits, take time to research the available options to ensure that you are getting the best provider for this highly useful technology.
Now that you understand the basics about PPE, take a look at Veridikal’s solutions and learn how our next generation DetectRx program takes PPE to a whole new level, providing your pharmacy with measurable results that help improve your bottom line so your pharmacy can prosper in 2023 and beyond.
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