How digital solutions saved more than $5m for a healthcare client’s specialty pharmacy group
Challenge
A large healthcare client faced two challenges:
- Cost-effectively manage a large volume of pre-certification requests for its specialty pharmacy business
- Simplify its complex and expensive distribution, administration, and patient management environments
With those challenges in mind, we identified several benchmarks to measure the success of our management program:
- Mitigate long turnaround times
- Accommodate both commercial and Medicare plans
- Adhere to contractual restrictions
- Abide by state regulations
- Improve both member and provider experiences
Human Ingenuity
Our multi-pronged approach delivered a management program with a strong focus on digital solutions:
- Digitally sorted, prioritized and routed faxed prior authorization forms to the appropriate destinations
- Automated the process for specialty medication pre-certification
- Created a standardized review system with nurse associates to determine if a patient request meets existing clinical guidelines or if it should be routed to medical directors for further assessment
- Streamlined provider phone requests for specialty drugs to identify pre-certification forms with complete information and forms requiring outreach calls for additional information
Results
For five consecutive years, the healthcare organization’s specialty pre-certification and pharmacy group realized an annual savings of more than $5 million dollars. Both commercial and Medicare plans contributed to the savings.