A collaborative technology platform can improve quality while reducing costs by automating the entire pharmacy prior authorization (PA) and utilization management processes. Ideally, this would include:
- Web-based formulary look-up support
- Web-enabled, end-to-end prior authorization management solution.
- Automated intake, routing, criteria verification, letter generation, and approval processes.
- Integrated full Rx history, benefit, and eligibility information.
- Rules-engine that employs all available clinical data and contains standard guidelines
- Fully configurable application for guideline, codes, letter templates and reports.
- Compliance with NCPDP-ePA and associated guidelines.
Such a solution can reduce manual PA workflow, improve the quality of the PA enforcement process, and automatically document all activities, thereby reducing approval response time and increasing physician understanding of lower-cost therapeutic alternatives.
4.) Outbound Technology
It’s important for health plans to inform and engage consumers using mail, interactive voice response (IVR), and other outbound technologies, while automating the creation of high-quality explanation of benefits. This allows health plans, PBMs and third party administrators to leverage daily member pharmacy claims by generating personalized member communications about pharmacy cost-savings opportunities, drug interaction alerts and drug-switching opportunities.
5.) One Database
The ability to reduce workflow costs by placing pharmacy and therapeutics decisions into one database accessible via the Internet has key advantages:
- Reduces administrative burden
- Improves response time to market-based requests for new formulary benefit designs and potential financial impact to plan sponsor
- Reduces costs by reduction in formulary errors during claim processing
- Increases compliance to myriad federal and state reporting requirements
- Facilitates formulary reporting to plan sponsors.
A web-based “single source” for all formularies and automating translation, conversion, and dissemination should:
- Transmit formularies automatically to e-prescription hubs and vendors, and synch updated formulary information for provider systems
- Employ clinician-oriented GUI design for easy querying, updating, extracting, and communicating the formulary data
- Support multiple drug identification compendia without impacting functionality
Privately run exchanges with participating insurers will require the ability to provide instant access to information. Brokers can play an important role by promoting a single-source technology platform that offers online tools designed to improve individual member behaviors and lower rates by improving overall workforce health and productivity. Ultimately, an optimized mobile-platform technology strategy will make it easier for health plans to meet members where they want to meet – and primarily at their convenience.
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