PROSPECTIVE MANAGEMENT PROCESS FOR MEDICAL BENEFIT PRESCRIPTIONS

• US 20110282690A1
• Filed: 05/13/2011
• Published: 11/17/2011
• Est. Priority Date: 05/13/2010
• Status: Active Grant

• Current Assignee: AXON Healthcare Services LLC
• Original Assignee: Rx Specialty Hub LLC
• Inventors: Escuder, Michael, Sampson, Melissa, Patel, Minalkumar, Charles, Mohan P.
• Granted Patent: US 10,475,140 B2
• Time in Patent Office: Days
• US Class Current: 705/3
• CPC Class Codes: G06Q 30/0603 Catalogue ordering
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 15/00 ICT specially adapted for medical reports, e.g. generation or transmission thereof
• CPC Class Codes: G16H 20/13 delivered from dispensers

Abstract

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.

Claims

1. A method for authorizing and dispensing medically-coded drugs, comprising:

providing a database of criteria for medically-coded drugs associated with a plurality of health plans and for patient identifiable information associated with said health plans;

interactively receiving an input from a user in which a particular patient is identified, a medically-coded drug is selected, a specialty pharmacy is chosen and a prior authorization request is submitted, wherein said user provides said input on behalf of a healthcare provider;

determining a health plan corresponding with said identified patient in said database and evaluating said criteria for said selected medically-coded drug;

providing an authorization code to said user corresponding with said selected medically-coded drug and said identified patient;

receiving a pharmacy dispensing report from said chosen specialty pharmacy, wherein said pharmacy dispensing report is associated with said authorization code and provides a pharmacy confirmation that said selected medically-coded drug was dispensed to at least one of said healthcare provider and said identified patient;

receiving a medical claims report from said health plan, wherein said medical claims report is associated with said authorization code and provides a medical confirmation that said selected medically-coded drug was administered to said identified patient at the approved dosage; and

updating said database with utilization data corresponding to said pharmacy dispensing report and said medical claims report.

2. The invention of claim 1, wherein said criteria for medically-coded drugs is health plan-specific criteria.

3. The invention of claim 1 further comprising the step of automatically generating a referral form corresponding to said healthcare provider and said chosen specialty pharmacy.

4. The invention of claim 1, wherein said user is a medical office staff member with said healthcare provider and wherein said authorization code is provided during a period of time wherein said user is engaged in said interactive session, wherein said period of time is within ten minutes following receiving said input from said user, and wherein said input further comprises a defined therapy criteria corresponding with said identified patient and said selected medically-coded drug.

5. The invention of claim 4 further comprising the steps of

automatically completing a plurality of data fields in an interface screen with information from said database based on said user input;

receiving periodic data feeds from said health plans, wherein said data feeds comprise eligibility data sets with health plan criteria and patients associated therewith;

automatically integrating said health plan criteria from said periodic data feeds into said criteria in said database and updating said criteria in said database with said health plan criteria from said periodic data feeds;

evaluating said criteria corresponding to said health plan of said identified patient and said selected medically-coded drug for said defined therapy criteria, wherein said therapy criteria is at least one of a duration period and a dosage level;

creating an authentication code as a unique transaction identifier between said healthcare provider and said identified patient for said selected medically-coded drug and said therapy criteria;

submitting said authorization code to said chosen specialty pharmacy;

performing a cross-walk process to reconcile said medically-coded drug with prescription drug codes; and

calculating a volume of medication from said cross-walk.

6. The invention of claim 5 wherein said cross-walk is performed after said medically-coded drugs have been ordered and dispensed, said cross-walk processing said pharmacy dispensing report and said medical claims report which are matched according to said authorization code.

7. The invention of claim 1, wherein said receiving step is further comprised of at least one of the steps selected from the set of steps consisting of:

receiving said input electronically through a computer network, receiving said input electronically through a computer system in combination with an automated telephony system, receiving said input orally through telephony between said healthcare provider user and a centralized data-entry service provider, and any combination thereof.

8. The invention of claim 7, wherein said oral receipt step further comprises the steps of said centralized data-entry service provider electronically entering said orally received input through a computer system and electronically receiving said input through said computer system.

9. The invention of claim 1, wherein said health plan determination step is further comprised of the steps of evaluating an eligibility of said patient in said health plan, evaluating a patient'"'"'s diagnosis relative to a first set of clinical policies in said health plan, evaluating a patient'"'"'s clinical values and site of care relative to a second set of clinical policies in said health plan, evaluating a specialty pharmacy selection relative to a set of dispensing options in said health plan, notifying said healthcare provider of a pending medical management decision, and docketing a pended request in a medical management reviewer dashboard for viewing and entering a disposition.

10. The invention of claim 9, further comprising the step of receiving from said healthcare provider user supporting documentation for a justified use of said medically-coded drug with said particular patient outside said clinical policies in said health plan according to said pending medical management decision.

11. The invention of claim 1, wherein said authorization code further corresponds with said chosen pharmacy and a preferred site of care and wherein said authorization code uniquely identifies and links said dispensed medically-coded drug with a drug order submitted by said healthcare provider.

12. The invention of claim 1, wherein said pharmacy confirmation further comprises a dosing detail at the NDC level and further comprising communicating patient information and educational materials to said healthcare provider through a patient exchange.

13. The invention of claim 1 further comprising the steps of accumulating said utilization data with a plurality of utilization data from a plurality of pharmacy dispensing reports and a plurality of medical claims reports associated with a plurality of respective authorization codes;

and preparing a utilization report from said accumulated data.

14. The invention of claim 1 further comprising the steps of:

performing a cross-walk process in which said pharmacy dispensing report and said corresponding said medical claims report are matched according to said authorization code and said medically-coded drug is reconciled with said prescription drug codes;

accumulating said utilization data with a plurality of utilization data from a plurality of pharmacy dispensing reports and a plurality of medical claims reports associated with a plurality of respective authorization codes;

preparing a utilization report from said accumulated data; and

reconciling rebate amounts according to said utilization report.

15. A method for authorizing and dispensing medically-coded drugs, comprising:

authenticating user rights to access a web-enabled login page as an authorized healthcare provider;

accessing a database through a healthcare provider interface page, wherein said database comprises criteria for a plurality of medically-coded drugs associated with a plurality of health plans and patient identifiable information associated with said health plans, said database further comprising information on a plurality of specialty pharmacies with capabilities to dispense a set of said medically-coded drugs, and wherein said healthcare provider interface page comprises a plurality of data fields;

entering input data into a plurality of data fields on said healthcare provider interface page, wherein said input data comprises information identifying a patient, a selection of a medically-coded drug from a listing of said medically-coded drugs and a corresponding therapy criteria, and a choice of a specialty pharmacy from a listing of said specialty pharmacies;

receiving additional information on said healthcare provider interface page that is automatically populated into said data fields from said database for said identified patient;

entering an authorization request on said healthcare provider interface; and

receiving an authorization code, wherein said authorization code comprises an authentication code as a unique transaction identifier between said authorized healthcare provider and said identified patient for said selected medically-coded drug and said corresponding therapy criteria.

17. The invention of claim 15, wherein said authorization code is received after entering said authorization request and while said authorized healthcare provider has authenticated user rights and is accessing said healthcare provider interface page.

18. The invention of claim 15, wherein said therapy criteria is at least one of a duration period and a dosage level.

19. The invention of claim 15, wherein said automatically populated additional information is selected from the group of information consisting of:

patient information, health plan information and therapy options.

20. The invention of claim 15 further comprising the steps of

receiving said selected medically-coded drug from said chosen specialty pharmacy;

administering said selected medically-coded drug to said identified patient; and

submitting a medical claims report to said database, wherein said medical claims report comprises said authorization code with a medical confirmation that said selected medically-coded drug was administered to said identified patient.

21. The invention of claim 20, further comprising the steps:

accumulating said utilization data with a plurality of utilization data from a plurality of pharmacy dispensing reports and a plurality of medical claims reports associated with a plurality of respective authorization codes; and

reconciling rebate amounts.

22. The invention of claim 15 further comprising the steps of repeating the steps of data entry, administering said medically-coded drug and submitting said medical claims report for a plurality of medically-coded drugs and corresponding patients, and after repeating the steps, receiving a report summarizing volumes of said medically-coded drugs administered to said patients, wherein said report contains a cross-walk key correlating said medically-coded drugs with corresponding prescription drug codes.

16. The invention of claim 26, wherein said authorization code is received within ten minutes after entering said authorization request.

23. A method for authorizing and dispensing medically-coded drugs, comprising:

providing a database of criteria for medically-coded drugs associated with a plurality of health plans and for patient identifiable information associated with said health plans;

receiving periodic data feeds from said health plans, wherein said data feeds comprise eligibility data sets with health plan criteria and patients associated therewith;

automatically integrating said health plan criteria from said periodic data feeds into said criteria in said database and updating said criteria in said database with said health plan criteria from said periodic data feeds;

receiving a login request from a healthcare provider;

verifying said login request is from a healthcare provider with rights to access at least certain medically-coded drug data and health plan data in said database;

displaying an interface screen having a plurality of data fields in which said healthcare provider can provide patient identifiable information and having lists of said medically-coded drugs;

interactively receiving an input from said healthcare provider, wherein said input comprises information identifying a patient and a selecting medically-coded drug;

automatically completing a plurality of said data fields with information from said database based on said healthcare provider input;

receiving a prior authorization request corresponding to said identified patient and said selected medically-coded drug for a defined therapy criteria, wherein said therapy criteria is at least one of a duration period and a dosage level;

verifying said identified patient satisfies said criteria in said database;

assigning an authorization code to said prior authorization request, wherein said authorization code comprises an authentication code as a unique transaction identifier between said healthcare provider and said identified patient for said selected medically-coded drug and said defined therapy criteria;

transmitting electronically to said patient a Drug Monograph, relevant messaging about a prescribed therapy, and calendar reminders about medication adherence;

receiving a pharmacy dispensing report associated with said authorization code, wherein said dispensing report comprises a pharmacy confirmation from a specialty pharmacy indicating that said selected medically-coded drug associated with said authorization code was dispensed to said healthcare provider;

receiving a medical claims report associated with said authorization code, wherein said claims report comprises a medical confirmation from said healthcare provider indicating that said selected medically-coded drug associated with said authorization code was administered to said identified patient;

automatically updating said database with utilization data corresponding to said pharmacy dispensing report and said medical claims report;

accumulating said utilization data with a plurality of utilization data from a plurality of pharmacy dispensing reports and a plurality of medical claims reports associated with a plurality of respective authorization codes;

preparing a utilization report from said accumulated data; and

reconciling rebate amounts.

24. The invention of claim 23, further comprising the steps of:

identifying non-selectable options that are not within a clinical policy;

wherein said clinical policy can be based on at least one of said identified patient'"'"'s policy with said health plan and said health plan'"'"'s overall clinical policies;

submitting said authorization code to a specialty pharmacy with corresponding information on said identified patient and said healthcare provider;

performing a cross-walk process on said pharmacy dispensing report and said corresponding said medical claims report having said authorization code to reconcile said medically-coded drug with prescription drug codes; and

calculating volumes of medications from said cross-walk.

25. A method for authorizing and dispensing medically-coded drugs, comprising:

providing a database of criteria for medically-coded drugs associated with eligibility data for a health plan and for patient identifiable information associated with said eligibility data;

receiving a login request from a user, wherein said user has an authorization from a healthcare provider;

displaying an interface screen having a plurality of data fields in which said user can provide patient identifiable information and having lists of said medically-coded drugs;

interactively receiving an input from said user, said input comprising an identification of a patient, a selection of a medically-coded drug, a choice of a specialty pharmacy, and a request for a prior authorization approval;

evaluating said criteria for said selected medically-coded drug and said eligibility data for said identified patient;

providing an authorization code to said user for said selected medically-coded drug and said identified patient;

transmitting electronically to said patient a Drug Monograph, relevant messaging about a prescribed therapy, and calendar reminders about medication adherence;

receiving a pharmacy dispensing report from said chosen specialty pharmacy, wherein said pharmacy dispensing report is associated with said authorization code and provides a pharmacy confirmation that said selected medically-coded drug was dispensed to said healthcare provider;

receiving a medical claims report from said healthcare provider, wherein said medical claims report is associated with said authorization code and provides a medical confirmation that said selected medically-coded drug was administered to said identified patient; and

updating said database with utilization data corresponding to said pharmacy dispensing report and said medical claims report.