Claim Conversion System for Denied Prescription Interception
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Solution Overview
Problem
Pharmaceutical manufacturers face challenges as prescription claims are often denied by claims processors, leading to financial burdens on patients and reduced utilization of prescription products, necessitating a system to intercept and convert denied claims to approved ones.
Innovation Solution
A computer-implemented method and system that intercepts denied prescription claims, determines available funding from pharmaceutical manufacturers or entities, and converts these claims to approved responses by allocating funding to pharmacies, thereby facilitating financial processing and claim approval.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Loss of energy
If claims processors deny prescription claims to control costs, then healthcare spending is controlled, but patient access to necessary medications is reduced and financial burden increases
Solution Approach 1:
The patent introduces a switch provider as an intermediary between pharmacies and claims processors. This intermediary intercepts denied claims and routes them to alternative funding sources (patient assistance programs, manufacturers, third-party payors), thereby maintaining patient access while preserving the claims processor's cost control function.
Solution Approach 2:
The system performs preliminary routing of denied claims to potential funding sources before final denial is issued. By proactively seeking alternative funding options and presenting them to the claims processor, the system converts many denied claims into approved claims, ensuring patient access while maintaining cost control through selective intervention.
2Productivity
If pharmaceutical manufacturers promote prescription products to physicians, then product utilization is enhanced, but claim denials by processors reduce actual product dispensing
Solution Approach 1:
The switch provider acts as a mediator that catches denied claims resulting from manufacturer promotion activities and redirects them to appropriate funding sources. This ensures that promotional efforts translate into actual product dispensing by resolving funding gaps between manufacturer pricing and payer coverage.
Solution Approach 2:
The system implements feedback loops where denied claims are routed back to manufacturers and other funding sources for review. This feedback mechanism allows manufacturers to understand denial patterns and adjust their promotional and pricing strategies to improve claim approval rates while maintaining product utilization.
3Reliability
If a system intercepts and processes denied claims through multiple funding sources, then patient access is improved, but system complexity increases
Solution Approach 1:
The patent segments the claim processing function into distinct modules: initial claims processing, denial interception, funding source identification, and funding allocation. This segmentation allows each component to specialize in specific tasks, improving overall system efficiency despite the increased number of components.
Solution Approach 2:
The switch provider is designed as a universal platform that handles multiple types of claims (pharmacy, DME, professional services) and interfaces with multiple funding sources (manufacturers, PBMs, third-party payors). This multi-functionality consolidates what would otherwise require separate systems for each claim type and funding source.
Data Source
AI summary
Systems and methods may be provided for claim denial conversion. The systems and methods may include receiving a prescription claim from a pharmacy, where the prescription claim is associated with a drug or other product requested by a customer, routing the prescription claim to a claims processor for adjudication, and receiving, from the claims processor, a denied claim response for the claim request. The systems and methods may further include determining that funding is available to cover at least a portion of a price of the requested drug or other product, converting the denied claim response to an approved claim response upon determination of the available funding, and transmitting the approved claim response to the pharmacy.