The Benefits of Automation: Pharmacy ePA

Jimmy SingkhaophetDirector of Strategy and Pharmacy at MHK

John Topolosky, RphManager of Pharmacy at MHK

Vinay Panchal PharmD, BCPS, Senior Pharmacist Manager of Pharmacy Benefit Prior Authorization at Blue Shield of California

User Summit, 2020

October 15, 2020

Session Objectives

Efficiency Gains from ePA

ePA Trends Analysis

Case Processing Benchmarking

Medical Part B Solution Overview

Pharmacy Quality

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The Benefits of Automation: Pharmacy ePA

In today's digital age, it is amazing that faxes still account for half the volume of pharmacy prior authorizations. It does not have to be this way. Learn how electronic prior authorization (ePA) can become a reality by understanding what is required and the benefits gained for the members, providers, health plans and PBMs.

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ePA Efficiency Gains

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Promote case avoidance and subsequent manual work associated with dismissals with up-front mock adjudication Improve prescriber prior authorization experience with near

real-time question set delivery Automatically map transaction information into the pharmacy

case UI eliminating manual data entry at Intake and Technician Review and reducing auto-forward risk associated with user error

Integrate MHK CareProminence Electronic Prior Authorization (ePA) in

real-time with EMR and ePA vendors for submission of electronic prior

authorizations and appeals in NCPDP format.

More up-front clinical information for internal users Reduced manual prescriber outreach via fax/phone Decreased RFI and downstream queue volumes

Prevent submission of incomplete question sets, resulting in:

Auto-approval capability promotes efficiency and reduces auto-forward risk

Transactional information systematically creates cases and eliminates manual data entry

ePA Efficiency Gains Continued

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ePA Efficiency Gains

Integrate MHK CareProminence Electronic Prior Authorization (ePA) in real-time with EMR and ePA vendors for submission of electronic prior authorizations and appeals in NCPDP format. Reduce operational average handle time by auto-scoring assessments, recommending case outcomes and promoting

efficient, accurate decisions. Permits auto-scoring of assessments as approvals which subsequently flow through MHK case workflow without a

manual touch – auto-approvals. Auto-approval capability expedites member access to medication, provides prescribers with near real time approval

confirmation and essentially equates to zero cost against operational processing expenses. Allows prescribers to quickly initiate an appeal and provide additional clinical information if the original coverage

determination was denied electronically. Decrease year-to-year training efforts and costs through reduction in manual case interventions.

Process equates to zero cost against operational processing expenses

60% or greater ePA rates achieved in short horizon

ePA Trends Analysis

ePA Fax PhoneJun-20 22458 9132 1014Jul-20 22985 9872 1123

Aug-20 24656 9296 1116

0

5000

10000

15000

20000

25000

Jun-20 Jul-20 Aug-20

68% 67%70%

28% 29% 26%

3% 3% 3%

Client A

ePA Fax Phone

ePA Volume Trends – Changing the Intake Paradigm

0

1000

2000

3000

4000

5000

6000

Jun-20 Jul-20 Aug-20

68% 65%67%

20% 22% 20%

5% 5% 5%

Client B

ePA Fax Phone

ePA Fax PhoneJun-20 5388 1566 400Jul-20 5504 1835 407

Aug-20 5732 1702 427

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ROI Improvements - Auto Approval Rates

Cases can be auto-approved if a reject code is found on the configuration table, a drug-specific decision tree exists AND an override template exists.

2020 success metrics (June-August 2020)

0

20000

40000

60000

80000

100000

120000

Client A (June - Aug 2020) Client B (June - Aug 2020)

12.1% of total volume

9.2 of total volume

Auto Approval Rates

Total Volume Approved ePA cases ePA Auto Approved Cases

Total Volume Approved ePA casesePA Auto Approved

Cases

Client A 102407 28758 12388

Client B 25059 7674 2313

Client A

• 43% of Approved ePA cases were auto approved

• This equated to 12.1% of total volume that required zero pre-decision manual touches

Client B

• 30% of Approved ePA cases were auto approved

• This equated to 9.2% of total volume that required zero pre-decision manual touches

ROI opportunities exist by creating more drug-specific DTs and ensuring proper reject codes are configured/returned. MHK partners with clients to identify these areas of opportunity to promote auto approvals and reduce volume in workflow tasks.

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ePA Guest Speaker: Vinay Panchal PharmD,

BCPS

Guest Speaker

Vinay has worked at Blue Shield of California for 7 years in various roles within the prior authorization team and is currently the Senior Pharmacist Manager of Pharmacy Benefit Prior Authorization. He has worked with MHK for 5 years and has been instrumental in taking advantage of the automation capabilities within the MHK pharmacy benefit prior authorization application. He graduated from University of California San Diego with a Bachelor of Science in Pharmacological Chemistry & earned a Doctor of Pharmacy degree from Thomas J. Long School of Pharmacy at University of the Pacific. Vinay is currently earning his Master of Business Administration from Forbes School of Business & Technology at Ashford University. Vinay has a passion to improve health and wellness through enhancing quality and the customer experience using innovation, data analytics and technology. He is driven by a strong desire to catalyze change, create sustainable impact & transform a dysfunctional healthcare system.

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Questions

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Case Processing Benchmarking

What can MHK do to help?

How can MHK help you identify where you stand on case processing time against other plans?

Are there areas where you can gain efficiencies from what other plans are doing in case processing?

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Benchmark Analysis

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Plan Compare

CD & RD Case Data MHK Client A MHK Client B MHK Client C MHK Client D

Monthly Case Volume* 6,712 7,291 30,983 576

Rx Tech Review Time Per Case (Minutes) 4.92 2.54 7.76 12.23

Number of Rx Tech Users 21 33 92 6

RPH Review Time Per Case (Minutes) 6.62 6.13 8.35 6.95

Number of RPH Users 9 17 41 7

Cases Per Tech Average (Monthly) 300 288 216 108

Cases Per RPH Average (Monthly) 306 402 250 75

Optimization Capabilities

Function Value Add

Upfront/Post Mock Test Claims

- Upfront mock allows for auto-population of Request Reason (UM edits)- If No PA returns, minimizes cases going through workflow- Post Mock ensures the override that went adjudications will pay at the pharmacy- If post fails, system allows user to correct to ensue patient will have no issues

ePA - Automatically maps transaction information into the pharmacy case UI eliminating manual data entry at Intake and Technician Review and reducing auto-forward risk associated with user error.

- Promotes case avoidance and subsequent manual work associated with dismissals with up-front mock adjudication

- Results in more up-front clinical information for internal users to render decisions- Reduced manual prescriber outreach via fax/phone leading to decrease RFI and downstream queue volumes- Ability to auto-approve cases without manual touch

Smart Processing

- Diagnosis code and claim-based rules- Discrete provider portal and core system decision trees- Any cases not auto-authorized pushed electronically to first clinical review queue- Allow for auto denial, such as diabetic test strips for Medicare, which are always Part B- Allows for cases to be auto-approved with little or no human touches- Improves data and decision quality

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Optimization Capabilities

Function Value Add

Override Templates - Auto-population of override screen to send to adjudication- Decrease of cases gong to Effectuation Exception for incorrect override values- Increase in overall auto-approval process for no user intervention

Auto Scoring (DT) - System scores clinical responses and recommends case outcomes based on decision tree configuration

- Promotes efficient, accurate decisions by end users- Provides ability to auto-approve cases, expediting member access to care while reducing

operational cost due associated with manual touches

Letter Auto-Triggers - Automation of triggering letters based off LOB, Status, Status Reasons, etc.- User does not have to manually sift through letters to see which letter to trigger- Eliminates possibility of triggering incorrect letter

IVR - Automated call to member- Auto-population of Member Oral Notification- Decrease manual calls out to the member- Decrease in cases going to Manual Outreach

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Questions

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Medical Part B Solution Overview

Overview of Part B Drug Functionality

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Ability to Differentiate Part B Cases from other Case types

using different Fax lines.

UI fields introduced for NDC and Jcode processing.

The Part B functionality designed to utilize the same

queue structure, workflow and efficiencies as Part D

component.

Multi- Tenant functionality leveraged to distinguish

between PBM clients delegated for Part B servicing (Part B NDC only or Part B NDC and J code).

Test claims button enabled or disabled based on NDC or J-

code and configured parameters.

Assignment allows independent assignment of Part B cases or common with Part D cases.

At prior authorization level, can direct Part B drug cases to

pharmacists and to Medical Director depending on plan

interpretation of appropriate clinical review.

Ability to deploy Decision tree upon Intake to determine B vs D. If B, continue processing. If

D, prompt to auto-create Coverage Determination case.

Captures Par/Non-Par, In Network/Out of Network.

Functionality

Overview of Part B Drug Functionality

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Can capture provider: requesting, servicing,

facility

Separate Part B dashboard portlet can be set up to

independently track Part B cases

IVR, letter and fax fulfillment functionality

remains

Captures all ODAG universe and Part C regulatory report

requirements

Additional Part B fields included in business

intelligence data mart

Same administrative configuration approach to

all functionality

As of 2020, all Part B drugs now must be processed within Part D SLA timeframes.

System will provide for calculating newly required Part B timeframes for Part B drugs System will apply longer ODAG timeframes to other benefits that may be processed but remain under the

traditional timeframes (e.g., DME/diabetic supplies)

Part B Step Therapy tracking to be provided to meet various regulatory requirements (e.g., application to new starts only).

Intake Screen

Once ‘New Case’ has been selected

then the Intake User is routed to Pharmacy Case creation for the Request Type

value of ‘Organization

Determination’.

User will have the capability to

enter multiple Jcode and/or

NDC.

Test claim button can be enabled or disabled based on

pre-determined logic including

how the drug(s) will be

adjudicated.

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Technician Review Case Screen

If Benefit Type is selected as ‘Medical’

Based on the Request Type of ‘Organization Determination’ and Benefit Type selection of ‘Medical’, ‘Rx’ icon will open a ‘Services Requested’ pop-window.

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If Benefit Type is selected as ‘Pharmacy’

Based on the Request Type of ‘Organization Determination’ and Benefit Type selection of ‘Medical’, ‘Rx’ icon will open a ‘Services Requested’ pop-window.

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Future of Pharmacy within Intake

Example Service Grid: Jcode and NDC

Example Service Grid: Jcode only

Example Service Grid: NDC only

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Flag Primary Code at Technician Review

The user can flag the Code as Primary using the Primary Code Checkbox option. This will override the Primary Code value in the Case UI Screen based on user selection.

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Decision Tree and Assessments

Organized in Multiple tabs / formed Definition sections

Multiple Decision Trees can be used in a single case for multi-determination

Link based on numerous levels including but not limited to: • Hierarchy• Attributes• Module components• Review Type • Role Access

Field Level Rules based on values for BvD criteria question sets Mandatory Hide / Show Disable / Enable Skip Logic Scoring formulas Cascade Logic

Data Element Options Select, Radio, Text, Large Text,

Label etc Multi-Select Tool Tips

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Questions

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Pharmacy Quality Solutions

Pharmacy Quality

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Ensure optimal therapeutic

outcomes for qualified

beneficiaries through improved medication

use

Reduce the risk of adverse events

Improve member’s medication

adherence rate

Conduct a comprehensive

medication review (CMR) between a clinician and the

beneficiary to discuss and assess their

medication regimen

Coordinate and engage care between the beneficiary and

their prescribers when an

intervention is needed

Continue to monitor and follow-up on the

beneficiary’s medication therapy

Medication Therapy Management (MTM)

Pharmacy Quality

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Medication Adherence / Drug Safety

Part D Star Ratings

Medication Adherence for Diabetes MedicationMedication Adherence for Hypertension (RAS antagonists)Medication Adherence for Cholesterol (Statins)

Identify non-adherent members utilizing industry standard PQA Measures and formula

Member and/or Provider Intervention(s)

Retrospective Utilization Review (RDUR)

Pharmacy Quality

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Ability to consume Acumen file or built-in stratification tool to proactively identify

OMS population

OMS response codes and prescriber responses

automatically recorded within MHK

Audit and export capabilities within MHK CareProminence

Built-in Acumen report for OMS Response and Sponsor

Forms

Initial prescriber outreach letter generated after verifying accuracy of

identified OMS criteria

2nd Attempt Prescriber Outreach letter automatically generated if member’s opioid prescriber unresponsive after 5 configurable business days

from initial outreach

Real-time dashboards to monitor open OMS cases

Overutilization Monitoring System (OMS)Medicare compliant OMS solution which is consistent with all CARA (Comprehensive Addition Recovery Act) guidelines

Functionality in OMS:

Questions

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©2020 MedHOK, Inc. The MHK logo, CareProminence, MarketProminence, and Where Care + Knowledge Converge are trademarks of MedHOK, Inc.

The Benefits of Automation: Pharmacy ePASession ObjectivesThe Benefits of Automation: Pharmacy ePA�ePA Efficiency GainsePA Efficiency Gains ContinuedePA Trends AnalysisePA Volume Trends – Changing the Intake ParadigmROI Improvements - Auto Approval RatesSlide Number 9Guest SpeakerQuestionsCase Processing BenchmarkingWhat can MHK do to help?Benchmark AnalysisOptimization CapabilitiesOptimization CapabilitiesQuestionsMedical Part B Solution Overview Overview of Part B Drug FunctionalityOverview of Part B Drug FunctionalityIntake ScreenTechnician Review Case ScreenIf Benefit Type is selected as ‘Medical’�If Benefit Type is selected as ‘Pharmacy’�Future of Pharmacy within IntakeSlide Number 27Decision Tree and AssessmentsQuestionsPharmacy Quality SolutionsPharmacy QualityPharmacy QualityPharmacy QualityQuestionsSlide Number 35