Medicaid

Model N Medicaid is a cloud-based solution designed for pharmaceutical manufacturers that need to manage Medicaid rebate calculations, claims processing, and compliance reporting. It addresses the risk that minor calculation errors can result in millions of dollars in overpayments or overcharge penalties, and that noncompliance with government requirements can lead to significant fines and reputational damage.

The solution supports compliance with federal Medicaid Drug Rebate Program (MDRP) requirements as well as state and supplemental programs. It translates regulatory requirements into operational execution and provides business insights to support ongoing Medicaid rebate management.

Key Benefits

• Regulatory compliance: Manages and processes payments for federal, state, and supplemental Medicaid programs.
• Reduced rebate overpayments: Supports timely payments to avoid interest penalties and runs validation tests to identify invalid units.
• Streamlined information sharing: Produces a consolidated payment package containing all required reports in a single action.

Core Features and Capabilities

• Regulatory Update Packs (RUPs): Delivers software and documentation updates to keep calculations and processing aligned with the latest regulatory changes, including current MDRP file format changes from CMS.
• Flexible formula builder: Correctly calculates unit rebate amounts (URAs) using 50 preloaded formulas, and supports changes in URA calculations through a configurable formula builder.
• Automated validations: Identifies outliers in claims through aggregated or prescription-level utilization data validations, reducing the likelihood of rebate overpayment.
• Streamlined report generation: Generates electronic Reconciliation of State Invoice (ROSI) and Prior Quarter Adjustment Statement (PQAS) reports.

Add-On: Medicaid Automated Invoice Retrieval

• Automates the retrieval of Medicaid invoices and claims to support more accurate and faster rebate processing.

Integrations with Model N Suite

• Integrates with Model N Validata for script-level validations to verify units at the Medicaid claim level.
• Receives up-to-date prices from Model N Government Pricing to ensure accurate rebate calculations.
• Provides information back to Government Pricing to support Public Health Service (PHS) price calculations.

Related Products

• Validata: A script-level validation tool used with Payer Management to confirm rebates are paid only on eligible dispensed products.
• Intelligence Cloud: Supports data-informed decisions using AI/ML, analytics, and reporting for revenue and channel management.
• State Price Transparency Management: Automates compliance with state price transparency regulations.

Model N Medicaid is part of the broader Revenue Cloud for Pharma platform. Since 2012, manufacturers have paid an average of $7.35 million for a single overcharge penalty, underscoring the financial importance of accurate Medicaid compliance management.