For independent pharmacy owners
Spot the MFP refunds that look short, late or missing.
Once a business associate agreement is in place, you will send your remittances and claims. Until then, we work from labeled synthetic data. The agent is built to list the refunds that look short, late or missing and draft the Good Faith Inquiry for you to review and send.
The agent is built to match each Medicare Maximum Fair Price refund to its claim and to your wholesaler invoice. You will answer a few questions and approve the drafts. A second service is built to help you answer a PBM audit.
We have not received a refund for claim SAMPLE-1001, dispensed 34 days ago. Please confirm its status. Invoice and claim details are attached.
Illustration with made-up sample data. This is a picture, not a working screen.
Sound familiar?
The refund comes weeks after I pay for the drug.
You front the cost at the counter and wait for the money to catch up.
Nothing lines up.
The 835, the MTF report, Beacon, my pharmacy system and my invoices do not talk to each other.
A short refund is easy to miss.
So few get disputed.
Every inquiry has a clock.
Each one needs claim details plus an invoice, and someone has to find them.
Then a PBM audit shows up.
It brings a claim list, a deadline and a pile of documents to pull.
NCPA members have reported refund delays and reconciliation problems.
Source: NCPA member reports. We are not affiliated with NCPA.
Job one
MFP refund reconciliation
The agent is built to check each Medicare negotiated-drug claim against the refund that came back and the invoice you paid. It will tell you which ones need a Good Faith Inquiry and draft it.
You review the drafts, and you submit them yourself.
How it works
- Send files
your remittances, your claim export and your wholesaler invoices. - Match
the agent is built to match each claim and flag the gaps, with the reason it found for each. - Review
the drafted inquiries, answer any question it has, and approve. - Submit
you submit them yourself. The agent is built to track the dates for you.
Job two, separate from the first
Got a PBM desk audit?
Send the claim list from the audit letter. The agent is built to prepare a per-claim evidence checklist and a draft response for you or your attorney. This is a different service from refund reconciliation, and you can use either one alone.
How it works
- Send
the audit claim list and the documents you already have. - Checklist
the agent is built to prepare a checklist for each audited claim: prescription image, signature and pickup proof, copay proof, and the invoice that covers the quantity. - Draft
it is built to mark what is missing, draft a cover letter, and list state-law items for you or your attorney to confirm. - Approve
you review and approve the packet, then you send it.
What it will not do
- It will not log in for you. It is built never to log into the CMS portal, Beacon or any PBM portal. Your staff sign in and submit.
- It will submit nothing without approval. Every inquiry and every audit packet is built to wait for a named person at your pharmacy to approve it.
- It takes no patient data yet. No patient data is accepted until a business associate agreement is in place with your pharmacy. Until then, demos use labeled synthetic data.
- It makes no promises. It does not guarantee any refund, recovery or audit result, and it does not give legal advice.
Questions
Do you guarantee I will get money back?
No. The agent is built to find and document the gaps. The manufacturer decides what happens to each inquiry, and some will not be paid.
Do you file the Good Faith Inquiry for me?
No. We plan to draft it with the claim and invoice details. You review it and submit it yourself.
What about patient data?
Claims and remittances can contain patient information. A signed business associate agreement comes before any real claim. Until then we use labeled synthetic data and talk with owners about how they work today. We do not claim HIPAA compliance.
Are you connected to CMS, NCPA or my PBM?
No. This is independent software. It is not affiliated with or endorsed by CMS, Medicare, NCPA, any PBM, any wholesaler or any pharmacy software vendor.
Is this legal advice?
No. The product is built to prepare documents. For a contested audit finding, your attorney advises you. State audit rules differ, so the audit packet lists items for you or your attorney to confirm.
Which pharmacy systems does it work with?
We expect it to work with any system that exports claims as a CSV file, plus your 835 remittance files. We will confirm that with each pharmacy before we start.
Talk through a real month with us
Join the pilot list. Or book a short demo on sample data.
Two quick questions help us most. Reply to either one in a line or two.
Tell us how many PBM audits you had in the last 12 months
Tell us how long your last MFP refunds took