Knowledge-Based Prior Authorization System for Specialty Drugs
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Solution Overview
Problem
Current systems for managing biotech/specialty drug prescriptions lack integration and automation, leading to inefficiencies in prior authorization, cost control, and data management for medically coded drugs, which are expensive and require professional administration.
Innovation Solution
A web-enabled, adaptive, and interactive knowledge-based system that integrates healthcare providers, health plans, and specialty pharmacies for real-time authorization and tracking of medically coded drugs, using NDC-level specificity and clinical policies to streamline the approval process and reduce costs.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Measurement precision
If manual auditing processes using HCFA-1500 forms are used to capture NDC numbers, then retrospective data collection is possible, but authorization time is excessively long and productivity is low
Solution Approach 1:
The patent replaces manual auditing processes with electronic data capture systems that automatically extract NDC numbers from prescriptions and transmit them through electronic interfaces between pharmacies, PBMs, and health plans, eliminating the need for manual form processing and significantly accelerating authorization while maintaining data accuracy
Solution Approach 2:
The system performs preliminary data capture and validation of NDC numbers at the point of prescription dispensing rather than waiting for retrospective auditing, allowing authorization decisions to be made based on pre-captured accurate drug identification data
2Loss of information
If retrospective manual auditing is used for medically coded drugs, then data collection is possible, but there is no prospective control over drug utilization and cost
Solution Approach 1:
The patent implements electronic data interchange systems that automatically transmit prescription data, NDC numbers, and utilization information in real-time between pharmacies, PBMs, and health plans, replacing manual retrospective auditing with prospective electronic monitoring that provides immediate data availability and rapid authorization
Solution Approach 2:
The system establishes real-time feedback loops where drug utilization data captured at the pharmacy is immediately transmitted to PBMs and health plans, enabling prospective monitoring and rapid authorization decisions based on current utilization patterns rather than waiting for retrospective analysis
3Ease of manufacture
If current manual processes are used for medically coded drugs, then billing can be performed, but integrated electronic authorization and tracking systems are absent
Solution Approach 1:
The patent merges previously separate manual processes for prescription processing, authorization, and tracking into a single integrated electronic system that handles medically coded drugs through automated workflows connecting pharmacies, PBMs, and health plans, maintaining billing simplicity while achieving high system integration
Solution Approach 2:
The system creates a universal electronic platform that handles multiple functions including prescription reception, NDC identification, prior authorization, utilization monitoring, and billing tracking within a single integrated workflow, eliminating the need for separate manual processes for each function
Data Source
AI summary
The present invention provides an interactive, electronic, knowledge-based ordering process for specialty/biotech pharmaceuticals (medically coded drugs) which results in less waste, improved procedural efficiencies, and greater cost savings than the current ordering systems. The knowledge-base of the system is based on the health plan's clinical policies as well as the status of the patient and their entitled benefits with the health plan, and it is applied in an interactive manner through a web-enabled system which provides a real-time, prospective examination and control over requests for authorization to dispense the medically coded drugs. The system also includes a feedback loop from the specialty pharmacies to provide information on the medicines that have actually been dispensed. The system also provides to the patient, educational material and adherence reminders to affect therapeutic outcomes.