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The payors for whom the pharmacies processed the highest volume of claims during the study period (number of claims > 200) were ranked according to the average number of days between date of service of reimbursement , average difference (loss) to the pharmacy, and percentage difference between number of claims billed and number of claims reflecting a difference. Rejected claims were not evaluated. Also, no adjustments made to the pharmacy's check for reasons other than differences described herein were included in this data. The data is presented in table 2.

Under the category of Percent Differences, two pharmacy benefit managers (PBMs) have a rank of 1 because neither of them was found to have claims where discrepancies occurred. However, both of these companies had relatively few claims examined.

PBMs ranked 4 and 5 had very similar percentages of difference, but the PBM ranked number 4 only had 614 claims examined and the average loss on each one was $29.81. The PBM ranked 5 had 3,788 claims examined, and the average loss on each one was $ 2.47. Obviously, the information presented about the PBM across all categories should be considered in making a decision concerning the acceptability of any particular company's insurance card.

To estimate the expected total cost in claim differences for the average pharmacy, three primary assumptions were made:

" Cost per difference ranged from $14.53 to $26.83 (i.e., $20.68+ $6.15) based on the 95 percent CI.
" Based on information gathered from the 1999 NCPA-Searle Digest, the average percentage of third-party claims ranged from 64 percent to 79 percent. An average pharmacy filled approximately 138.6 prescriptions per day. Thus, from 88.7 to 109.5 prescriptions a day were paid by a third party based on a 280 day-year.
" Differences in the paid versus claim amounts occurred in 0.98 percent of claims based on the figures presented above.

Based on these assumptions, it was determined that an average independent pharmacy can expect to lose approximately $6,623 dollars a year from differences in claims, or approximately $0.14 per third-party prescription. Additionally, the sensitivity analysis revealed the average "best case" scenario is a loss of $3,537 ($0.14 per prescription), and the average "worst case" scenario is $8,061 ($0.26 per prescription).
To roughly estimate the loss for a particular pharmacy based on the above results; we can use the following equation:

LOSS=$20.68 x (Claim Difference Rate) x (Third-Party Percentage) x (Prescriptions Filled Per Year)

For instance, if an independent pharmacy fills 40,000 prescriptions a year, 70 percent of the prescriptions will be third-party claims. If the pharmacy estimates from its records that approximately 1 percent of the claims are paid a different amount than that billed, then the pharmacy will be losing approximately $5,790 a year of $20.68 x .01 x .70 x 40,000 = $5,790.

CONCLUSIONS

It is important to realize that the percentage of claim differences plays the most important role in calculating these expectations. In the example above, if the pharmacy has a low percentage of claim differences (e.g., pharmacy 7 at 0.05 percent), then the fictional pharmacy in the example above may only lose $290 a year. Therefore, it may not make sense for the pharmacy to reconcile each claim. However, if the pharmacy has a high percentage of claim differences (e.g., pharmacy 5 at 5.96 percent), then the same pharmacy may be losing as much as $34,510 a year!

One final note: At the beginning of the study period, only two of the seven pharmacists were reconciling their third-party reimbursement statements. After participating in the study, six of seven pharmacists now perform claim reconciliations every month.