Mike Brown and Laura McIntire-Hansel, May 15, 2024
Remote models for prescription claims adjudication that unlock greater opportunity for delivering patient care
While many health systems are exploring or expanding specialty pharmacies as a strategy to extend care to patients and generate prescription margin, their success depends on successful prescription claims adjudication — which is becoming a growing challenge.
“Implementing a specialty pharmacy model is complex,” notes Mike Brown, vice president of managed services for Cardinal Health, which operates 75 outpatient and specialty pharmacies across 25 states for hospitals of all types. “We find that many overlook the resources required to navigate payor approval of prior authorizations or lack needed support to connect patients to programs that help them better afford their out-of-pocket cost of medications.”
Without addressing the resources required to process claims and minimize rejections and denials, a patient’s out-of-pocket costs can skyrocket. “Without payor coverage, high-cost specialty medications are typically unaffordable,” states Brown. “Even with payor coverage, some patients have difficulty paying their co-pay amounts. Instead, we see more patients choosing to postpone or abandon treatment. As a result, the health system loses the opportunity to care for that patient — and ultimately the health system will write off unpaid medical bills as a loss.”
In fact, a recent Gallup poll found that today almost 40% of patients1 decide to postpone medical care due to costs, regardless of payor access or the seriousness of the health condition. “The trend is alarming,” notes Brown. “It tells us that if specialty pharmacies lack sufficient resources to process prescription claims and access programs to assist with cost of care, they could miss serving an average of one of out of every three patients.”
Moving beyond the building blocks for specialty pharmacies
Brown explains that many specialty pharmacies focus on foundational operational tasks, such as patient consultations, maintaining accreditation compliance, accessing insurance networks and staffing and retention.
“Understanding the intricacies of claims adjudication is rarely prioritized,” Brown adds. “Typically, pharmacy schools do not cover the intricacies of billing a claim to a payor — that is learned through on-the-job experience. Combined with recent pharmacy labor challenges, having knowledgeable staff who have learned the ropes to successfully adjudicate claims can be a challenging goal.”
Laura McIntire-Hansel, director of revenue cycle development for Cardinal Health, explains that the expertise and labor required to adjudicate claims can be underestimated since processing prior authorizations takes time and often needs to be submitted multiple times.
For example, for one health system client with a cancer center and affiliated specialty physician practices, 82 percent of the specialty pharmacy’s prescriptions over a 45-day period required additional processing to adjudicate. One of its clinicians estimated that each prior authorization took almost an hour to process — multiply that by each patient served in a given day, and it quickly adds up. McIntire-Hansel explains how current staffing challenges in specialty pharmacies impact the ability to manage them all.
For another six-hospital health system client, almost all of its specialty pharmacy prescriptions over three-month period routinely require multiple steps — an average of two touches per prescription claim. “If a pharmacist processes five prescription claims per day, this equates to as much as 10 hours of staff time. Without an alternate approach to support this activity, pharmacists would have little time remaining for patient care activities,” adds McIntire-Hansel.
The connection between quality care, patient advocacy and specialty medication claims adjudication
“The potential benefits of increasing claims approvals are many-fold,” McIntire-Hansel notes. To help health systems meet this challenge, Cardinal Health developed one of the first remote claims support models for health system specialty pharmacies, Cardinal HealthTM AtrixTM Ally.
“By providing remote support for claims adjudications and patient advocacy support, on-site specialty pharmacists can operate at the top of their license and focus on clinical tasks and patient care,” explains McIntire-Hansel.
McIntire-Hansel also notes that the increased prescription capture impacted patient care and the pharmacies’ bottom lines in these two health systems. Up to 64 percent of the initially rejected or denied prescriptions were later approved for payor coverage and patient advocacy opportunities.
“AtrixTM Ally also enables specialty pharmacies to expand services,” notes Brown. “One of our clients is expanding the specialty pharmacy to serve its employees as well as its patients. In a period of expansion and personnel constraints for specialty pharmacies, this approach ensures that quality care continues.”
“With the ongoing increase in utilization of specialty medications, hospitals need to rethink how they can extend care for chronic or critically ill patients who depend on these medications for their treatment regimen.”
Brown explains that effective claims adjudication is no longer just a financial or administrative function in healthcare — it directly affects patient care. Health systems must ensure their outpatient and specialty pharmacies can support this function, as it is just as important as selecting a pharmacy model or accessing payor networks.
“Remote support models like AtrixTM Ally, especially when combined with a high-performing specialty pharmacy, are critical to supporting the hospital’s mission of care to its patients” notes Brown.
References: 1. CNBC.com: “Record high share in U.S. report delaying medical treatments due to costs — here’s how you can save on health care” Published January 20, 2023 (accessed March 7, 2024), By Annie Nova https://www.cnbc. com/2023/01/20/americans-put-off-health-care-because-of-cost-how-you-can-save.html#:~:text=The%20share%20of%20Americans%20who,taking%20the%20measurement%20in%202001
*Individual results vary based on volume, acuity and specialty.
