Payers now have an adjudication “highway” of data flow for providers’ prior authorizations, including step therapy requirements.
Bi-directional data sharing is now possible while decreasing administrative expenses.
Step therapy requires patients to try less expensive drugs before they can get a more expensive drug. It's also known as "fail first" or "step protocol.”
Requirements
Patients must try and fail less expensive drugs before they can get the more expensive drug.
A doctor must submit a prior authorization request form to the health plan for approval.
The health plan won't cover the more expensive drug until the lower-cost medication has failed.
Purpose
To control health care costs.
To ensure that all clinically sound and cost-effective treatment options are tried before more expensive medications.
Why is it so expensive to administer a health plan?
The $700 Bn industry comprises over 30+ functions, each with 100s of complex workflows.
Why is each function so costly? Because there is a constant flood of unstructured clinical data coupled with an ever-shrinking pool of skilled labor who manually processes all this messy data.
It’s a data problem and an intelligence problem.
Meet Payer™ -
A co-clinician and Adjudication Team on demand
With GENIUS’ PAYER™, we combine an intuitive clinical reasoning AI platform and PA adjudication “highway” for physicians that provides:
An immediate and complete repository of all global FDA drug label data, including the latest pharma clinical studies with citations for audit, is updated daily to allow for DDI, allergies, co-morbidities, and black-box warnings against suggested new drug regimens.
Patient-specific EHR records and adherence monitoring are sent back and forth via our proprietary X12 health data adjudication “highway.”
Payers’ PA process is reliable and justifiable.
GENIUS’ PAYER™ is a true self-serve platform that operates within the clinic and extends to all payers.
GENIUS’ PAYER™ helps with the exhaustive burden of prior authorization
The use of AI bot-to-bot or “battle of the bots” is a stop-gap solution. It’s like building a truck instead of using a highway. GENIUS’ interoperable end-to-end platform is the more intelligent latter.
How it works: Patients must try less expensive medications before they can access more expensive ones. Patients and their doctors must document unsuccessful attempts at treatment with the less expensive options. Prevalence: A 2021 review found that 38.9% of drug coverage policies used step therapy.
Challenges: Step therapy can be frustrating for patients, especially those with serious or chronic conditions. It can also add administrative complexity to the HCP and staff.
If your new prescription requires step therapy, the pharmacy looks back at your drug history to see if you’ve tried the step therapy within a given time period. If you have, the pharmacy fills the prescription as usual. Suppose you haven’t previously tried a step therapy. In that case, the pharmacist will work with your doctor to get a different prescription or work with your doctor and insurance company to request coverage for the initially prescribed drug.
Bottom line: Good luck with the current workflow. This data provided back to payers doesn't usually include lab values, doctors’ notes, or any measurable efficaciousness of current step medication.
Enter PAYER™ by GENIUS.
Our proprietary solution includes our FDA-cleared patient app (that is nurse-monitored).
We transmit patient adherence back to providers, allowing them to compare it against current patient lab tests and drug regimens to measure efficaciousness and for greater intelligent clinical care decisions.
After the provider's review, audit, and completion, the results are sent to any payer as a completed PA with our X12-designed data flow.
We solve for the Medical Necessity Review (MNR) within the payer’s PA process - that is evidenced and explainable - thus reducing the payer’s op-ex spend.
Speeds up manual clinical reviews by 10-15x.
Clinicians and MNR staff are shown evidence from medical records and AIDA™, our patient adherence app.
Conclusion is full explainability and audit trail with no black box interpretation.
GENIUS is an X12 featured licensing partner along with meeting TEFCA and Carequality frameworks.
super-power your pA process with Payer™
See how GENIUS, a fully interoperable suite of enterprise-level AI platforms, can transform the relationship between patients, physicians, payers, and pharma.