Real-Time Prescription Adjudication via Inventory Synchronization
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Solution Overview
Problem
The existing prescription medication fulfillment and payment processes are complex and prone to errors, leading to lost revenue for sponsors and program processors, as well as inconvenience and overpayment for patients, due to inefficiencies in determining the most cost-effective adjudication method between standard rates and discount programs.
Innovation Solution
A computer-implemented system that automatically determines, in real-time, whether a prescription drug claim is eligible for a discount program by comparing inventory levels and pricing information from remote databases, allowing for immediate adjudication at the lowest cost, thereby reducing costs for patients, sponsors, and program processors.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Productivity
If conventional manual prescription processing methods are used, then operational flexibility is maintained, but processing speed and accuracy deteriorate due to complexity and human error
Solution Approach 1:
The system enables self-service automation where the adjudication system automatically determines eligibility and selects the most cost-effective program without human intervention. The processor automatically retrieves pricing information, compares costs across programs, and makes adjudication decisions, eliminating manual processing while maintaining system complexity management through automated workflows.
Solution Approach 2:
The patent replaces manual mechanical processing with automated electronic systems. The processor automatically retrieves pricing information from databases, performs cost comparisons across multiple programs, and makes adjudication decisions through electronic workflows, substituting human manual operations with automated computational processes that increase speed and accuracy.
2Loss of time
If real-time automated adjudication is implemented, then processing efficiency improves, but system complexity and data retrieval requirements increase
Solution Approach 1:
The system performs preliminary actions by pre-retrieving pricing information from remote databases before the actual adjudication decision is needed. The processor automatically obtains current pricing data for multiple programs in advance, so when a prescription needs adjudication, the comparison and decision can be made immediately without delay for data gathering.
Solution Approach 2:
The patent introduces intermediary components including remote databases that store pricing information and a processor that acts as an intermediary between the prescription input and the final adjudication decision. These intermediaries manage the complexity by organizing data retrieval and processing workflows, allowing real-time adjudication without requiring the entire system architecture to be overly complex.
3Reliability
If multiple inventory levels are maintained separately, then program eligibility accuracy improves, but inventory management complexity increases
Solution Approach 1:
The system applies segmentation by maintaining separate inventory levels for different programs (e.g., 340B inventory versus standard inventory). This segmentation ensures that prescriptions are adjudicated against the correct inventory based on program eligibility, improving accuracy. The processor retrieves pricing and inventory information specific to each program, ensuring that the most cost-effective program is selected while maintaining proper inventory tracking for each segment.
Data Source
AI summary
Computer-implemented systems and methods for synchronizing network databases for an electronic inventory manager. The system includes a computer network and a remote database communicatively coupled to the computer network. The remote database is configured to store information related to whether a prescription drug is included in a select program at the time of processing a prescription drug claim. The system includes a client device configured to synchronize a quantity of the prescription drug claimed by the patient over the computer network and approve the claim under the select program. The system includes an electronic inventory system configured to determine whether the prescription drug claim is eligible to be fulfilled with the select program and synchronize the value of the inventory level at the electronic inventory system associated with the select program.