Pharmacy Services solution sheet
Are you up for the challenge?
Health plans and pharmacy benefit managers (PBMs) face a myriad of challenges, coming from multiple directions, and seemingly all coming at the same time.
- Gaps in care
- Rising costs
- Increased fraud, waste, and abuse
- Decreased efficiency and effectiveness
- Member provider abrasion
EXL Health looks and goes deeper to find a better way to empower Pharmacy leaders to improve operational effectiveness, enhance clinical and financial outcomes and reduce member and provider abrasion.
Introducing EXL Health pharmacy services
EXL Health’s Pharmacy Services embodies human ingenuity to proactively and comprehensively help our clients manage their pharmacy programs. We deliver services that resolve the most complex problems of pharmacy leaders by focusing on what matters most – improving member outcomes and quality, containing costs, and ensuring members and providers receive the best experience possible.
Our predictive and prescriptive analytics solutions, clinical, quality and utilization management services, workflow technology, and prescription claim auditing capabilities help enhance pharmacy operations, drive digital transformation, turn raw data into a strategic asset, and provide powerful population health insights that let our clients stay competitive and achieve market growth and expansion.
Pharmacy utilization management
Create efficiencies and accuracies across utilization management (UM) operations that drive cost containment and quality outcomes while enabling pharmacy resources to focus where needed most.
- Execute authorization process via flexible engagement model (delegated, partial delegation, non-delegated, onshore/offshore)
- Proactively manage waste
- Proactively manage pharmacy spend
- Deliver services to impact efficiency and effectiveness
Pharmacy quality & care management
End-to-end care management services leverage HEDIS, STARS and Pay for Performance (P4P) quality measures to improve member care and to support customer’s objectives in total cost of care reduction and delivery on contractual commitments.
- Identify and manage quality gaps in drugs, drug-disease and drug-age interactions and alerts
- Define and measure improvement targets
- Improve quality measures, including medication adherence, high-risk medication utilization, and inappropriate drug use
Payment integrity
Control costs associated with incorrectly billed or overpaid pharmacy claims, focusing on prevention, avoidance and recovery.
- Effectively conduct contract, payment policy and fraud, waste, and abuse reviews
- Identify instances of overpayment
- Increase pharmacy compliance
Pharmacy operations & digital transformation
We are constantly innovating to deliver new and advanced digital solutions to transform pharmacy operations for our clients. We do this by leveraging cloud technologies, advanced analytics, and by embedding natural language processing (NLP), machine learning, conversational AI and robotics/automation into current workflows. EXL Health combines this approach with the deep domain knowledge of our techno-functional experts. Having the rich experience of working with numerous clients and technology partners, we are well positioned to drive significant value and business outcomes for care management operations.
Our platform agnostic, highly modular digital solutions can be rapidly applied to deliver the following key benefits:
- Improve member/provider engagement and satisfaction
- Reduce cost to serve
- Improve operational accuracies and efficiencies
- Reduce cycle time
Population & risk analytics
Proprietary population and risk analytics are the foundation for delivering successful outcomes across care management programs. Driven by client data, our advanced analytics provide a comprehensive member view and deliver actionable insights into opportunities to impact member health, quality outcomes and medical costs.
EXL enables our clients to:
- Provide a holistic member view
- Improve member engagement by identifying the most effective communication methods and known preferences
- Proactively identify members most in need of care
- Prioritize member outreach and engagement based on impactability1 and intervenability2
Market growth & expansion
Segment your market, identify and monitor trends, maximize enrollment and prioritize opportunities and invest accordingly.
- Augment market knowledge with member and provider profiling, personas and abrasion analysis
- Stratify patient populations by risk
- Understand current market landscape
Proven outcomes
A top national PBM needed an efficient process to review pharmacy claims for discrepancies/errors prior to payment. EXL Health’s auditor expertise, predictive analytics and IT resources developed a scalable and repeatable program across all lines of business to avoid inappropriate payments.
A large healthcare company was looking for a cost effective way of managing the volume of precertification requests for its specialty pharmacy business and its complex and expensive distribution, administration and patient management environment.
Our Pharmacy Services utilization management solution employed a multi-pronged approach, including developing a process for precertification requests for specialty medications.
Indentified top discrepancies to pinpoint needed behavior change and outliers
Improved network communication and compliance
Realized 20M+ ($1.6M/month) in annual cost avoidance
EXL Health is a longterm, true partner. They have collaborated with us on the best strategy and execution of our care management platform, and positioned us for success in automating our processes. EXL empowers us to deliver complex and technical solutions needed to exceed our customers’ expectations.
Frank Maguire, MD Chief Network Officer, TriWest Healthcare Alliance
They have really deep, deep, analytical knowledge. They are easy to work with. They bring a wealth of data science knowledge to the table. If you want to have a really good analytical discussion about your data with somebody, they’re the people to talk to.
Director of Care Management Blues Plan
Human ingenuity Bringing
“Together, we will do this” to life
At EXL Health, human ingenuity is the catalyst with which we solve your complex problems. Our experts look and go deeper, to find a better way to improve outcomes in terms of clinical outcomes, quality, total cost of care, and member/provider experiences. Our team is also nimble, willing and able to adapt to dynamic industry trends and to adopt new techniques and technologies to accelerate your transformation and to support your continued growth and success.
EXL Health associates take a consultative approach that adapts to your evolving needs. We collaboratively engage with you to fully understand your current and dynamic business challenges and to develop innovative solutions to address those challenges. This approach results in much more than a transactional interaction. It establishes and nurtures a long-term business relationship, a partnership. Together, We Will Do This is more than just a marketing headline – it’s a commitment, a promise.
Why partner with EXL Health?
Our diverse, global resources and delivery models allow us to provide capacity on demand, on- and off-shore.
Our practical experience provides us with unique perspectives, knowledge and applied learnings across the healthcare continuum, offering timely insights to complex challenges.
Our cross-market expertise – Fully- and Self-insured Commercial segments, Medicare Advantage, Managed Medicaid, Health Information Exchanges – allows us to drive relevant, member and patient-centric insights, recommendations and outcomes.
Our innovation is “always on,” whether it’s developing more efficient processes or finding and leveraging new data assets, new technologies, new analytics methodologies and techniques.
To learn more visit: https://www.exlservice.com/industries/health-and-life-sciences