Prescription Claim Routing Rules for PBM Selection and Pricing
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Solution Overview
Problem
Existing systems fail to efficiently route prescription drug claims to the most suitable pharmacy benefit managers (PBMs) based on customizable selection criteria, leading to suboptimal pricing and increased out-of-pocket expenses for customers.
Innovation Solution
A prescription drug claim routing system that utilizes a set of rules to select the appropriate PBM from a plurality of options, modifying routing information to ensure optimal pricing and payment plan flexibility by considering customer-specific criteria.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Measurement precision
If existing routing systems are used, then claims can be routed to PBMs, but pricing is suboptimal and out-of-pocket expenses increase
Solution Approach 1:
The system changes routing parameters by applying customizable selection criteria to determine the optimal PBM for each claim. Instead of using fixed routing rules, the system dynamically selects PBMs based on variables such as pricing, customer preferences, and plan characteristics, thereby optimizing pricing and reducing out-of-pocket expenses.
Solution Approach 2:
The routing system transitions from static routing decisions to dynamic selection. The system continuously evaluates multiple PBMs against customizable criteria and adapts routing decisions in real-time based on claim-specific characteristics and customer preferences, enabling optimal pricing throughout the claim lifecycle.
2Adaptability or versatility
If multiple PBMs are available, then pricing options increase, but routing complexity increases
Solution Approach 1:
The system segments the routing decision process into distinct components: claim intake, criteria evaluation, PBM selection, and routing execution. This segmentation allows the complex task of selecting from multiple PBMs to be broken down into manageable steps, each handled by specialized modules within the routing system.
Solution Approach 2:
The routing system acts as an intermediary between claims and PBMs, managing the complexity of multiple options. It receives claims, applies selection criteria, determines optimal PBMs, and handles routing logistics, thereby providing payment plan flexibility while containing routing complexity within a centralized management layer.
3Measurement precision
If customizable selection criteria are applied, then pricing optimization improves, but system complexity increases
Solution Approach 1:
The system performs preliminary actions by pre-configuring customizable selection criteria and storing PBM information in advance. This preparation allows the routing system to quickly evaluate claims against predefined criteria without complex real-time calculations, improving pricing accuracy while managing system complexity through pre-processing.
Data Source
AI summary
Systems and methods for routing packages between a plurality of computer network originator systems and a plurality of computer network processing systems. The computer network routing system can include one or more processing circuits including one or more processors and memory storing instructions that, when executed by the one or more processors, cause the one or more processors to perform operations. The operations include providing an interface for registering at least one user with a computer network routing system, wherein the at least one network is at least one of a local area network (LAN), wide area network (WAN), a telephone network, a wireless link, an intranet, or internet. The operations include issuing at least one UPC to the at least one user. The operations include receiving and selecting a computer network processing system. The operations include updating at least one first data segment and transmitting the routing package.