PSP Benefits Verification

Electronic verification of Pharmacy Benefits

Context

Life sciences organizations implement patient services programs (PSPs) to provide essential support services such as benefits verification, financial assistance, therapeutic guidance, and outcomes management. These programs cater to patients who have recently been prescribed or are currently using commercially available medications or therapies. The primary goal of these services is to ensure that patients can readily identify suitable treatment options, obtain timely and affordable access to medications, and ultimately achieve optimal clinical outcomes.

Timely and accurate delivery of appropriate medication is crucial for positive healthcare outcomes. Pharmacy Benefits Verification is a critical component in this process, as it ensures that patients can access their prescribed medications without encountering delays or facing unforeseen financial obstacles. However, the complexities of payer systems, frequent changes in coverage policies, and the intricacies of specialty medications often make benefits verification a time-consuming and error-prone task.

Scenario

Cumulus Pharma, a life sciences organization, has launched a new Diabetes Management Program (PSP) to provide comprehensive support to patients like Lisa Green, who was recently diagnosed with diabetes. As a patient services representative for this PSP, Lief is responsible for verifying Lisa's pharmacy benefits after her enrollment. This involves confirming her insurance coverage and calculating the costs associated with her prescribed medication. Traditionally, this process requires Lief to gather information from Lisa and her healthcare provider, then contact Lisa's insurance provider via phone, email, or fax to obtain details about medication coverage, copay, coinsurance, deductibles, and out-of-pocket expenses. This manual approach is time-consuming and often involves multiple interactions with the insurance company.

Solution

With the Patient Services Benefits Verification Integration App, Lief can electronically verify Lisa's pharmacy benefits. Organizations like Cumulus Pharma can configure this integration app to connect with FHIR-compliant third-party clearinghouses or payers. This connection automates the benefits verification process by sending the verification request, receiving the response, and updating the coverage information within Salesforce.

Benefits

Electronic Benefits Verification significantly increases representative productivity by minimizing the time spent on manual verification tasks. This allows representatives to dedicate more time to meaningful patient engagement, develop a deeper understanding of their individual needs, and provide enhanced support throughout their healthcare journey. Additionally, the streamlined process facilitates faster access to care and promotes improved prescription adherence by patients.