Hi everyone! I need your advice.
I have been working with Truven MarketScan® Commercial Claims and Encounters Database and the Medicare Supplemental and Coordination of Benefits (COB) Database in the past, and most recently with the SEER-Medicare data.
The oncology medicines I am working with are either injectable ( antibodies or targeted treatment) or chemo ( I guess it can be both orally taken or given infusion in an out-patient setting). I want to pull out all the claim information about the medicines. Should I just use J-code to pull them out from the in-patient (part A in Medicare) and out-patient (part B in Medicare) database? These medicines also show up as NDC# in the pharmacy database ( Medicare part D). Should I include the pharmacy claims in my analysis? All the medicines are reimbursed by Part B in Medicare. I don't understand why they show up in the pharmacy claims (part D). The patients wouldn't go to a pharmacy to pick up an oncology drug right?
Thank you so much for your advice!
Thank you for your answer, Vivek! Pricing in Red Book like AMP and WAC are referenced prices. I am looking for real-world cost information.
You should pull claims from both pharmacy and medical claims, including part B. One thing you need to decide is if you are looking for cost of drug only or the cost of the visit (ie, infusion/chemo) would include all costs for the same day of service at that location. Also keep in mind that with Advantage programs, prices are often dependent upon provider agreements, so there won't be a standard reimbursement cost for drug/procedure and these prices may have no relation to ASP set by CMS. Keep in mind, depending upon the time of the year, member costs should also be considered as well as paid costs for total cost of service. Also keep in mind that the data is as good as the source, and every state and Insurer has a different way of loading claims and creating extracts for CMS.
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