Specialty drug claims are notoriously expensive and complex, comprising an estimated $243 billion of U.S. pharmaceutical revenue in 2023. Due to their complexity, specialty drug claims are prone to inaccurate billing, fraud, waste, and abuse (FWA). Prior authorization is the main source of claims verification for many plans, but the nuances of specialty drugs claims require more than the automated processes that prior authorization can offer. Relying solely on this approach may allow for missed savings opportunities or inappropriate billing during the payment cycle. In our newly updated white paper, director of audit operations Matthew Herbein and I outline best practices for handling specialty drug claims for better accuracy and faster payment.

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