Case Study: Technology Provides Solution to Challenge with Annual Benefit Verifications


The ability to automate a medical benefit investigation is bringing new efficiencies to the hub and delivering better outcomes for providers, patients, and manufacturers.

New Year. New Benefits. Same Challenge.

Looking back, it’s no secret that January was a stressful time for all those engaged in providing patient access services, as many people rang in the new year with a new benefits package. As a result, manufacturers (and their hubs) typically scramble to help providers and patients understand how these benefits affect a patient’s existing therapies.

The most common approach to this challenge has been for the hub to staff a small army of temporary workers to meet the growing demand for benefit verifications (BVs). The model is extremely expensive and inefficient because staff must be recruited, onboarded, and trained each year only to be repeated the following year.

Fresh Thinking for an Old Problem

A large international biopharmaceutical manufacturer decided to take a hard look at this issue for their market leading biologic portfolio. Within the organization, the issue even had a name. Aptly dubbed the “Blizzard” for the flurry of benefit verifications that occurred each January (north of 50,000 additional BVs), the management team was aware of the business impact of using inexperienced workers to perform BVs at the same time of the year that payers’ call volumes were at peak levels.

The manufacturer had a clear vision for what they wanted to achieve. First, accelerate the turnaround time to complete a BV. Making providers and their patients wait weeks to understand how their new plan design would affect ongoing therapy was no longer acceptable.

Second, improve the accuracy of the data returned in the benefits investigation. It was not uncommon for the provider and/or patient to receive incomplete or inaccurate coverage guidance, which typically could be traced back to either the payers’ rep or hub rep’s human error.

Third, if possible, reduce costs and the amount of management resources consumed to plan and execute the annual Blizzard.

The Evolution from Manual Labor to Automated Processes

Given the aggressive and far-reaching objectives, the management team did not believe incremental improvements to the current labor-intensive business model could deliver the desired results. Instead, a full transformation of the process in which the BV was completed was required. The team realized that both automation and accuracy were critical factors to a successful Blizzard redesign.

As such, they developed and tested automation and accuracy benchmarks along with strict operational standards.

The manufacturer had previously incorporated an automated medical benefit investigation process into its systems and was reaping the operational and economic benefits of this powerful transaction. So, why not explore how an automated benefits investigation could add value to the Blizzard project?

A plan was designed to enable requests for benefit investigations to be processed in bulk via the automated benefits investigation process. The protocol required the transactional provider to accept a batch file containing tens of thousands of BV requests, process them, and within hours return all BV results to the hub in a predetermined statement of benefit format.

Technology Tames the Blizzard

The manufacturer had historically hired approximately 400 temporary workers during the Blizzard period in hopes of completing the lion’s share of the 50,000 BVs over the course of 6 weeks. In this case, fortunately, history did not repeat itself. By incorporating the automated benefits investigation process into the Blizzard, the manufacturer achieved, and in some areas, exceeded its objectives.

Highlights include:

  • More than 50% of the BV requests were successfully automated using this powerful transaction. Instead of taking several weeks to complete, providers and patients had more than half of their results returned in the first few business days of the year.
  • Problem Patients Identified. One of the main goals of the Blizzard was to identify patients whose insurance coverage had changed. By leveraging the automated benefits investigation process, the hub was able to identify nearly 5000 patients who changed plans and focused more resources to those cases.
  • Major full-time employee reductions. With far fewer manual BVs to process, the manufacturer significantly reduced its temporary workforce while realizing material cost savings.
  • Automation drove improved levels of accuracy. Given the automated benefits investigation process’s real-time connectivity to live payer data, a significant number of Blizzard BVs no longer were processed by an inexperienced hub call center agent asking questions of an overworked payer’s rep and then manually recording information.
  • Operational standards and consistency were improved for the BV. Automated transactions, by their very nature, reduce the likelihood of individual (human) process variation and result in greater adherence to data and quality standards.

Although manufacturers cannot change the fact that each year many patients will have substantial changes to their benefits and coverage design, the ability to automate a medical benefit investigation en masse is bringing new efficiencies to the hub and delivering better outcomes for providers, patients, and manufacturers.

The following chart depicts the key features and benefits of an automated benefits investigation.

Source: VirMedica’s automated benefits investigation process, called the MedeBV.

Related Videos
Image Credit: SciePro -
Pharmacist selling medications in the pharmacy | Image Credit: rh2010 -
Atopic dermatitis on a patient's hand -- Image credit: Ольга Тернавская |
biosimilar word or concept represented by wooden letter tiles on a wooden table with glasses and a book | Image Credit: lexiconimages -
Image credit: alicja neumiler |
Laboratory test tubes and solution with stethoscope background | Image Credit: Shutter2U -
Laboratory test tubes and solution with stethoscope background | Image Credit: Shutter2U -
Image credit: |
Human brain digital illustration. Electrical activity, flashes, and lightning on a blue background. | Image Credit: Siarhei -
© 2024 MJH Life Sciences

All rights reserved.