Prior Authorization Application with "PBM in a Box" Solution
Industry
Healthcare
Service
Application Development
Technologies
Angular 9, ReactJS
Client
Leading Healthcare Enterprise
Understanding the Challenge
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.
The US Healthcare industry has a group of "middlemen", collectively known as PBMs – Pharmacy Benefit Managers. They have made use of the Prior Authorization Application (PA), a cost-saving 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.
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.
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.
Project Highlights
Process Automation
Configurable workflows with dynamic document templates
Rules Engine
Decision support and automation configurators
Regulatory Compliance
Government-sponsored program compliance built-in
Multi-platform
Web application with mobile & tablet roadmap
Behind the Scenes
When you walk into a medical store with a 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 — via call, fax, or 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 expedited. A standard case needs to be approved within 72 hours, but an expedited case has to be approved and delivered in 24 hours.
Each LOB (line of business) has a different workflow, with multiple steps through which a query must pass. Once a case is created, it undergoes review. During this process, there might be a hold-up — a doctor's approval or additional documents may be required. Since this is automated, the case automatically moves to a waiting list and once all the stipulations match, the system takes an automated decision.
The 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 and proceeds to claim adjudication.
The 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, leading to a non-transparent model of business.
What our client proposed was a solution for this very problem — "PBM in a box".
When they approached Cloudium for application development, 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 workflows
- Dynamic document template definitions & automated document generation
- Rules configurators for decision support and automation
Tech stack: For UI development, ReactJS and Angular 9 were used. Different entities like PA, Benefit, Eligibility, Formulary, etc., are built as Angular or React projects, housed under a single-page root application using ReactJS.
The Benefits
Cloudium was involved with solution architecture, development and testing. The platform was designed and built to meet complex, continuously evolving government-sponsored program compliance and regulatory requirements.
Increase Shareholder Equity
Reclaim Control Over Drug Spend
Own Your Data
Increase Member Satisfaction
Improve Performance Metrics
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