Formulary Messaging System for Pharmacy Claim Alerts
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Solution Overview
Problem
The management of formulary information at retail pharmacies is time-consuming and affects profitability and customer service, as pharmacists lack information about formularies before submitting claims, leading to inefficient dispensing decisions and increased out-of-pocket costs for patients.
Innovation Solution
A system that generates actionable formulary messages for pharmacies before submitting claims, identifying preferred drug alternatives and reducing patient out-of-pocket liabilities, by parsing claim data and providing alerts on non-preferred products, allowing pharmacists to discuss and authorize alternative medications before dispensing.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Loss of information
If pharmacies submit claims without prior formulary information, then the claim processing follows the standard workflow, but pharmacists cannot influence dispensing decisions and patients face higher out-of-pocket costs
Solution Approach 1:
The system performs preliminary formulary checks and generates formulary messages before the pharmacy submits the claim. This advance provision of formulary information allows pharmacists to make informed dispensing decisions and contact physicians about alternatives before the claim is processed, eliminating the need for post-claim corrections and reducing overall processing time.
Solution Approach 2:
The patent introduces an intermediary formulary message system between the pharmacy and the payer. This intermediary provides formulary information and alternative drug suggestions to the pharmacy before claim submission, enabling pharmacists to make informed decisions without delaying the standard claim processing workflow.
2Reliability
If pharmacists review free-text claim response messages after claim approval, then alternative products can be identified, but most pharmacists do not read these messages and re-work occurs
Solution Approach 1:
Instead of providing formulary information in post-claim free-text messages that pharmacists overlook, the system generates structured formulary messages and delivers them to the pharmacy practice management system before claim submission. This ensures pharmacists have the information they need at the point of decision-making, eliminating the need to review missed post-claim messages and reducing re-work.
Solution Approach 2:
The patent replaces the ineffective mechanical approach of relying on pharmacists to manually review free-text messages with an automated electronic messaging system integrated into the pharmacy practice management system. This automated delivery mechanism ensures formulary information reaches pharmacists reliably and is properly displayed for review.
3Ease of operation
If patients discover high out-of-pocket costs at pickup, then they may refuse the purchase, but by then the pharmacy has already performed dispensing work
Solution Approach 1:
The system provides formulary information and alternative drug suggestions to the pharmacy before the claim is submitted and before dispensing begins. This allows pharmacists to inform patients of lower-cost alternatives in advance, enabling patients to make informed decisions about their prescription costs before the pharmacy invests time in dispensing work, thereby reducing re-work when patients refuse high-cost prescriptions.
Data Source
AI summary
Methods, systems and computer program products alert pharmacies of formulary alternatives. A claim generated by a provider and including at least one drug is received, where the claim is directed to a payer recipient. The claim is reviewed to identify the at least one drug. The at least one drug is then compared to a pre-established formulary alternative table, which may be created or managed, at least in part, by the payer recipient. A preferred drug alternative may then be forwarded to the provider when the at least one drug has a match in the pre-established formulary alternative table.