Prior Authorization Application with "PBM in a box" solution


With Google and Wikipedia at our fingertips, many of us are more or less educated on common symptoms that accompany an illness, be it a simple cold or a minor heart attack, and are able to act immediately to counteract it. We also have the freedom to get over-the-counter medicines. You know, the funny thing is, we are so educated and think so highly of ourselves that for many of the usual sickness, we treat ourselves. Now, don’t get me wrong, a Paracetamol for fever or Ibuprofen for pain relief is common knowledge. What is alarming is that these and many other medicines can be gotten without any prescription.
The US Healthcare industry has a group of “middlemen”, who are collectively known as PBMs – Pharmacy Benefit Managers. They have made use of the Prior Authorization Application (PA), a cost saving’s feature that helps ensure the appropriate use of selected prescription drugs. The working theory was pure and true to the cause, but, when it came to practice, many craved for the Midas Touch. What is it that we can do to take control of our lives, as well as, the life of our near and dear ones, back into our hands?
A leading enterprise in the healthcare industry proposed a solution – develop a software allowing you to reclaim control of your prescription drug benefit program, with cutting-edge technology that includes innovative administrative, operational and clinical services solutions. They approached us at Cloudium to bring this to fruition. PA is an automated process everywhere. So, what is different here? Our client wanted to bring about a change in how PBMs were perceived. That it is not just a cut throat business, it provides you with a feasible yet quality care.

  • Scope
  • Industry Healthcare
  • Service
  • Technologies

01 Behind-the-scenes

I. When you walk into a medical store with that prescription and the pharmacist enters your details into the system, an alert goes off automatically at the other end. If the drug needs a prior authorization, according to your prescription benefit plan, a query is sent. Now, this can be in the form of a call, fax or an email. It is linked to a workflow, which is automated. There are certain attributes that are an extension of the case, whether it is standard or expediate. A standard case needs to be approved within 72 hours, but an expediate has to be approved and delivered in 24 hours.
II. Each LOB (line of business) has a different workflow, which has multiple steps through which a query pass.
III. Once our case is created, it has to undergo a review. During this process, there might be a stuck-up. It could be a doctor’s approval or that additional documents are required. Since this is an automated function, the case automatically moves to a waiting list and once all the stipulations match, the system takes an automated decision. Another aspect to this is, whether the drug requested is formulary or non-formulary. Now, this approval is based on a questionnaire corresponding with the formulary. The answers are scored on an autoscore logic. When satisfied with the scores, a case is approved.
IV. Now that the approval is a success, it has to go for claim adjudication. Since the approval happened in our system, an intimation is necessary to process the claim and it is for this purpose that overrides are created. The respective amount calculation is based on the corresponding percentage given in the health benefit plan of a patient.

02 Solution

PBM is not a new development in the healthcare industry. It has been in existence since the 1970s. Even though it began as a cost-effective means for the general public to get quality healthcare, PBMs soon realized the potential for money-making. It led to a non-transparent model of business, which is also the biggest criticism against them. What our client proposed was a solution for this very problem – “PBM in a box”.
When they approached Cloudium for application development, we were not too concerned with the work we had to put into it. After hearing their ultimate goal, our team realized that this was not just a profitable business tool; this was a humane act that can save countless lives.
Our proposal included Process Automation through configurable work-flows, dynamic document template definitions and automated document generation and delivery as well as rules configurators for decision support and automation.
This is available as a web application, soon to be accessible on smartphone and tablet as well; all of this is made possible with our technology stack –
i. For UI development ReactJs and Angular 9 has been used. Different entities like PA, Benefit, Eligibility, Formulary etc., are built as an Angular or React project.
ii. We have also created a single page root application using ReactJs. The whole project is housed under this root application.

03 Benefits

We, at Cloudium, was involved with solution architecture, development and testing of the application. The platform developed was designed and built to meet the complex and continuously evolving government sponsored program compliance and regulatory requirements. It provides you with the following benefits -
>> Increase shareholder equity,
>> reclaim control over your prescription drug spend and operations,
>> own your data,
>> increase member satisfaction, and
>> improve performance metrics.

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