A survey conducted jointly by National Public Radio, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health found that although most Americans have insurance that includes prescription drug coverage, more than one-third of adults said that either they, or a member of their household, were denied coverage for a prescribed medication in the past year.
Pharmacists, of course, understand the frustration and heartbreak of not being able to provide a patient with their doctor's first-choice medication. Pharmacists also understand that more times than not, these patients will simply choose to go without their medications. And when that happens, treatable conditions often escalate, resulting in the need for hospitalization and other types of high-costs medical resources.
Now though, there are ways for pharmacists to intervene and help patients receive their prescribed medications. Two specific technology-based solutions are now available and helping to facilitate patient access to medications. These solutions, both available to private, non-government plans include:
- eVoucher services which locate and apply manufacturer copay discounts at point-of-sale, enabling patients to reduce their out-of-pocket costs. eVoucher capabilities generally work as follows:
- A pharmacist receives a patient's prescription and enters key information into the pharmacy's technology system.
- The prescription information is routed to the appropriate plan/payer via the pharmacy's technology system (such as PrimeRx™ from Micro Merchant Systems.) Information is returned to the pharmacy regarding formulary coverage, patient co-pay amounts, prior authorization requirements, and any step therapy protocols.
- AT THE SAME TIME THOUGH, eVoucher capabilities determine if the manufacturer of the prescribed medication offers a voucher to help offset the patient's out-of-pocket costs.
- Should an eVoucher be available, the system will notify the pharmacist of the revised co-pay amount, and automatically adjust the patient's account.
- Denial conversion capabilities are uniquely offered to PrimeRx™ pharmacies. Pharmacies are reimbursed, by Micro Merchant Systems, for providing a medication to a patient after the patient's claim has been rejected by a payer. The rejected claim is converted to "paid" status, thereby allowing the patient to receive the medication. Pharmacies offer a real-time notification confirming each reimbursement. In addition to a reimbursement for the cost of the medication, pharmacies receive an administrative fee to cover time and processing costs.
Micro Merchant Systems has bundled these capabilities into a single interface called MMS eVoucher and Denial Conversion Services. This innovative solution is included with the PrimeRx™ pharmacy management system and has been embraced as a valuable tool in improving pharmacy efficiency, maximizing revenue, and improving patient access to medications. Key pharmacy benefits include:
- Ease of use: The eVoucher solution provides pharmacies with electronic coupons to help reduce patients' out-of-pocket expenses on select prescriptions. The software automatically identifies and applies coupons when a prescription is processed through PrimeRx™. No additional steps for a pharmacist are necessary. Once a coupon is identified, the system automatically applies the savings and makes the necessary adjustments to patient and pharmacy records within PrimeRx™. Denial conversion is triggered when a payer rejects a claim as non-reimbursable for a selected drug or medical device. The denial conversion solution automatically "converts" the denied prescription to "paid," and sends a message to alert the pharmacist. Micro Merchant Systems reimburses the pharmacy for the cost of the medication, plus an administrative fee as follows:
- For each denial conversion transaction, the pharmacy is paid the Wholesale Acquisition Cost (WAC) + 7.5% for the submitted drug program or medical device, less the patient responsibility amount.
- Pharmacies also receive a $2.00 per transaction fee to cover administrative costs.
- Improved revenue. Since the eVoucher and denial conversion services help patients receive their preferred medications – usually higher-priced, upper-tier medications – pharmacies can expect a resulting increase in sales and revenue.
- PrimeRx™ pharmacies receive direct reimbursement for providing patients with previously denied medications.
- Pharmacies also benefit from a $2.00 administrative fee paid for each denial conversion transaction.
- Decreased prescription abandonment/increased sales. With patients able to leave the pharmacy with their medications, pharmacists can expect reduced instances of patients opting not to fill, or refill, their medications.
The NPR/Robert Wood Johnson/Harvard study made clear that far too many patients are unable to obtain their prescribed – and preferred – medications. Pharmacists experience this on a daily basis, and understand that in many instances, denied coverage results in patients going without their medications. Now though, with MMS eVoucher and Denial Conversion Services, there is a way to address the serious issue of prescription drug claim denial.
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