Smart Claim Variance

Owned by Colin.Campbell
Nov 08, 2022
2 min read

Many variances are due to incorrect settings, so it is helpful to first do a manual calculation of the subsidy price and check your data so that you and HealthSoft can have the same settings if more checks are required. Variances are also caused by claim as you go on drugs owing.

Formula used for calculating the subsidy price (or amount claimed):

Subsidy price = Subsidy Cost + Schedule Markup + GST + PSF

Use the Pharmaceutical Services fee and % markup for the month you are claiming your script in.

Markup=………………………

PSF=…………….. (incl. GST.)

for ………..… (month)

Rx#……………………..

Drug……………………

Quantity dispensed……………

Subsidy cost for (1 pack of ………………………..) =

Subsidy cost for (………..) (quantity dispensed)=

Therefore:

Subsidy price= Subsidy cost + Schedule markup+ GST + PSF

=………………+…………………….+ 12.5% +…………..

=____________________

For example:

If markup is 3.5% and PSF is $5.51 then

Subsidy price = subsidy cost + 3.5% + 12.5% +5.51

Or Subsidy Price = $subsidy cost x 1.035 x 1.125 + (5.51)

Amount payable = Subsidy price patient co-payment

For an patient the amount claim = Subsidy price - $

Therefore the amount payable = $………………… - $……………….

= _________________

 There are a few factors which will result in a variance between the RxOne estimate of amount claimed compared to HealthPac amount paid. In order that your query is directed to the organisation who can assist you best, please check the following before contacting HeathSoft, Pharmac, the MoH or HealthPAC:

  • The right schedule markup and PSF was used at the time of dispensing.

  • Check the computer subsidy cost with the Pharmac schedule for that period, if that corresponds then the Pharmacy program is using the right subsidy cost. If the subsidy cost from the HealthPAC report does not correspond with the Pharmac schedule subsidy cost then please contact HealthPAC.

NOTES

  • There will be a few situations where the price estimate that RxOne makes will differ from the payout that HealthPAC makes. These situations will become less as we plug the gaps, and are not a cause for concern since the estimate is only that, an estimate . Health Benefits always recalculates the price from the quantity and pharmacode and pays on that, not on the estimate. Even with a few variances we would expect the estimate to normally be within $1 in $1000 of the actual correct payout.

 ROUNDING. There will be minor rounding differences on some items, which will cancel out over a batch.

 

When checking a batch, remember that it is not an error if the payout differs from the estimate, it is only an error if you are paid the wrong amount.

If there is a significant variance between RxOne estimation and HealthPAC payout and its not due to the above reasons, please email us your manual calculation and the variance report.

Our experience of running Electronic Claims on over 1000 pharmacies in other countries for many years, is that Electronic Claims is many times more accurate than the previous manual pricing.