Smart phones. Thumbnail-sized microprocessors. Information at the speed of now. Advances in technology can be found virtually everywhere, including in the delivery of medical services and prescription benefits.
Smart Business spoke with Daryl Corr, the president of Healthesystems and a pharmacy benefit management (PBM) industry expert, about unique ways technology is being used to improve processes in the workers’ compensation pharmacy environment.
How is technology today helping to shape the delivery of prescription benefits?
Technology has had a profound effect on the PBM industry, due to the transactional nature of the service delivery model. One of the key functions a PBM performs is managing prescription drug transactions directly with the pharmacy, right at the point of sale. This includes communicating information, ranging from program eligibility and medication plan design rules, to managing contract rates and transaction authorizations. However, the role of the PBM must extend beyond solely facilitating the financial transaction since more can be done to control the cost of medications, including avoiding the dispensing altogether. And this is greatly enhanced using the proper technology to manage the process.
When dealing in workers’ compensation, the need for more robust technology is even greater. Unlike a typical group health pharmacy program, which involves a co-pay or cash sale, workers’ compensation transactions should occur with no cost to the claimant. In addition, group health prescriptions tend to be less ambiguous to the pharmacy than workers’ compensation since determining a patient’s eligibility is clearer. Frequently, workers’ compensation eligibility is uncertain since the claim may have yet to be reported and often the drugs require more scrutiny since they are usually pain medications.
A PBM who employs real-time technology communicates with the pharmacy instantaneously, at the critical point of dispensing, and can therefore prospectively apply the proper edits and process a successful pharmacy transaction. In addition, the PBM is immediately alerted when a prescription is blocked or requires a prior authorization.
As is the case with any workers’ compensation pharmacy program, payers want all prescriptions processed in-network and therefore prospectively adjudicated, where all clinical rules, pricing, eligibility, etc., are applied before the prescription is dispensed. That’s one of the most basic functions of any effective PBM program.
