Overall contract flow
Receiving the contract from the contracting team
click to edit
Receiving data from our customers (as an invoice)
Setting the contract up in the system
System has other master data such as product, pricing, eligibility, contract etc.
Systems arent really designed to execute value-based contracts
Have to figure work around on how to set up value based contracts with the existing system
There could be different price groups for each quarter and can get challenging to set up
It gets complex because there is a lot of data points to be handled
Amendments to the contract can happen
VBC is an amendment to the existing contract
Problem of backdating is complicated (cant set it up until signed, lot of back and forth between legal teams)
Activation of contract
Send that data to IT to load into Validata (DLR) (sometimes through email or through FTP depending on the account)
Invoice into a 3rd party (IQVIA) to start the validation of the formulary (shared through FTP)
Once DLR is received from IT, validation is completed, based on the list from Stan
They send a file to IT after validating the formulary
Validation (standard and contract specific ones)
Exported from Validata into ModelN
It arrives at submissions
Approve it
Push to adjudications
Formulary is uploaded into ModelN
click to edit
Check if pricing is accurate based on contracts (through push of a button)
Identify discrepancies, pay the calculated amount
Cannot do validation at our end because of unavailability of patient persona/category level data
Create rebate approval package, contract development team need to approve it or could be escalated up to CFO
reports are generated out of ModelN, and the package needs to be put together
Once approved, Amy goes into ModelN to sign it (mostly electronic)
Packages can be accessed through file share
Amy validates one final time to verify the approved sum and payment sum, in the SAP system
Sends the payments along with a report (no front end communication is done unless to sync on formulary)
Need to stick with the contract terms for payment - how many days to pay - mostly 60 days - clock starts - time sensitive
There are contractual terms on when the invoices need to come in. This is verified by contracting team.
Payers could dispute and demand that we pay- can involve legal teams
If GSK agrees with dispute, then we can process payments on original data file
Or it could lead to adjustment, and payers would send new data sets, and goes through the whole process flow to payment
This happens more frequently than imagined
Disputes can be on formulary, 340B
If dispute is about formulary - payers have to prove that the right products are dispensed
If 340B - more communications with the customer electronically (email or FTP based on customer). Reconciliation file has all the details on the dispute
Most data comes in a standard format. But some don't come in NCPDP format
Checks the date to verify if claims are meant for this quarter or a back-bill
Sometimes the back-bill could go up to 11 months adding to complexity
There is a cut-off for back-bill in the contracting