What role does technology play in improving communication?
Maintaining high network utilization (in-network transactions) is a key metric for any successful PBM program. In order to achieve this, it is crucial to resolve any unnecessary transaction rejects at the point of sale. The sooner a PBM identifies an initial reject, and proactively resolves it with the pharmacy, the more likely the transaction will process in-network since it is less likely to be billed retrospectively on paper. When filling a workers’ compensation prescription, if a pharmacist receives an initial reject, there is a high likelihood it will be processed out of network, and sometimes the pharmacist is unable to make a call due to time constraints. Therefore, the insurance payer may not receive network rates, and pays a higher price for the prescription.
Based upon our stats, communication with the pharmacy must happen within a narrow window of time or the transaction is likely to process out of network. We are talking minutes. As you could imagine, this becomes even more critical when the injured worker is waiting at the pharmacy counter — which is about 15 percent of the time. You need every part of the pharmacy program process to succeed and happen fast. Which means immediately alerting the claims professional when a prior authorization is required, rejecting the inappropriate scripts before they get dispensed and quickly assisting the pharmacy when necessary.
A successful PBM’s service model must support proactive and immediate communication between the pharmacy, the insurance payer and the PBM. To help both the payer and the pharmacy, a PBM must be able to see and react to these situations in true ‘real-time,’ with a process to proactively engage and clear obstacles for transactions to occur in-network.
Is technology being used on the front line as well? Does it play a role in the day-to-day management of a pharmacy claim?
Real-time technology, Web-based applications and self-service tools are all being utilized to help claims professionals manage workload and assist workers’ compensation claimants. Healthesystems provides clients access to Vertic, a proprietary online claims portal where claims professionals can process transactions, review claims histories and use reporting and analytic tools.
The more time a PBM can save for a claims professional by providing a streamlined, easy-to-use and accurate claims management environment, the more time they can actually spend ‘managing’ a claim. A powerful Web portal, such as Vertic, presents the most relevant and critical data, allowing claims professionals to make more informed treatment decisions. In fact, by incorporating prescription history and clinical tools into a claims portal, treatment outcomes can be significantly improved, assuring injured workers receive the right drug for the right treatment.
The key to all of this pharmacy technology is to ensure the management of quality data and quickly turn it into actionable information. <<
Daryl Corr is the president of Healthesystems. Contact Healthesystems at (800) 921-1880 or [email protected]. For more information about Healthesystems, visit www.healthesystems.com.
