A Change in Provider Workflow to Help Improve Patient Care and Health Plan Satisfaction

 |  Austin Raper, Ph.D.

Hero 2018 11 09

Health care in the U.S. is a complex ecosystem that often leads to operational inefficiencies that can frustrate both providers and patients. Communication among providers, pharmacists, payers and patients is vital for understanding what matters to each. At CoverMyMeds, we work hard to facilitate discussion among stakeholders to identify bottlenecks in health care and innovate solutions to improve efficiency, with the mission of helping patients get the medications they need to live healthy lives. One such solution, RxBenefit Clarity™, connects payers with providers and patients to remove the guesswork concerning which medications are covered and how much they will cost.

Navigating the complex health care system is top of mind for health plan members. A 2018 report by J.D. Power and Associates found that 47 percent of those surveyed expressed that they did not completely understand how their health plan works and cited frustration at the lack of clarity for when a medication or treatment requires prior authorization (PA).1 Even with such time and cost saving technologies as electronic prior authorization (ePA), patients still perceive PA as an inconvenience and this is reflected in poor satisfaction scores for payers.

Payers are listening and sympathize with the concerns of health plan members. According to a recent survey of top executives from health plans and pharmacy benefit managers (PBMs), member satisfaction is recognized as one of the most important areas for improvement in the coming year.2 To address the problem of uncertainty around PA for certain medications and services, payers are pivoting toward real-time benefit check (RTBC) technologies.

To understand what RTBC is, it’s important to first consider the current convention of prescribing. At the doctor’s office, a patient is examined and diagnosed before being prescribed a therapy by the health care provider– typically with little consideration for if the medication is covered under the pharmacy benefit of the patient’s health plan. Consequently, when a medication is prescribed that is not on the health plan’s formulary, a PA request is most often retrospectively initiated in pharmacy as the patient attempts to pick-up their prescription, thus delaying start of therapy. In fact, 66 percent of claims for prescribed medications rejected at the pharmacy require a PA and 36 percent of these prescriptions are abandoned by the patient, presumably because the drugs cost more than expected!3,4 For more information on ePA, checkout the 2018 ePA National Adoption Scorecard.

Unfortunately, patients often perceive the administrative checkpoint of PA as red tape and a failure on the part of their health plan.1 Real-time benefit check presents an alternative approach to prescribing within the provider workflow that circumvents this hassle for the patient. At the point of prescribing, RTBC solutions are able to surface health plan benefit details on an individual patient basis, including co-pay and deductible information as well as if a PA will be required for the medication. Advanced RTBC solutions like RxBenefit Clarity™ not only provide the most accurate health plan benefit details but go a step further to provide cash price for medications, preferred alternative medications that are on formulary, pharmacy-specific pricing for medications and, when a more expensive therapy is necessary for the patient, the possibility of patient assistance programs to help shoulder the high cost. Armed with all of this information, the patient and provider can have a productive conversation about a personalized journey for therapy that considers all facts– medical, temporal and financial.

The power in RTBC is that providers can make more informed prescribing decisions earlier in their workflow to optimize the utility of PA for the patient by choosing from alternative, on-formulary therapies at the point of prescribing, if clinically appropriate. As a result, patients may enjoy a reduced time to therapy and likely see their health plan in a new light. Moreover, the administrative burden and cost associated with PA requests can lighten for providers, pharmacists and payers alike. Real-time benefit check offers a platform for interoperability within the health care industry that will only benefit the major stakeholders that share the common ground of helping patients.

To discover more on how an RTBC solution, like RxBenefit Clarity, can help to evolve the health care industry, visit the 2018 Real-Time Benefit Check National Adoption Scorecard.


  1. J.D. Power 2018 Commercial Member Health Plan Study, 2018
  2. Point of Care Partners Research, November 2018
  3. 2018 ePA National Adoption Scorecard
  4. 2018 Real-Time Benefit Check National Adoption Scorecard
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