Optimizing Technology During New Client Transitions

Specialty Pharmacy TimesJune 2012
Volume 3
Issue 3

It's all about communication when transitioning new business contracts, and that process will require careful oversight, successful data exchange, and a flexible approach.

It's all about communication when transitioning new business contracts, and that process will require careful oversight, successful data exchange, and a flexible approach.

After several months and dozens of sales calls, you finally land that contract between your specialty pharmacy and a large payer. Congratulations! Now, let the real fun begin! It’s time to execute a seamless member-focused transition.

More than likely, you will be transitioning your new business from an incumbent that may not be happy that it has lost the business. Accurate and timely receipt of transition files will be critically important. Data exchanges are typically performed utilizing standard file layouts transmitted through secure encrypted connections and will include the following files: Member Eligibility, Open Refill, and Prescription Fill History. Eligibility and claims data files will be needed in order to establish a patient health record, load member history, and conduct utilization reviews. Open Refill Transfer files are also needed to ensure that patient therapies are maintained upon transition. Patient enrollment and prescription history information should be directly imported into the pharmacy management system, as this information will be utilized to determine the patient’s date of next required fill as well as allow the scheduling team an opportunity to coordinate medication delivery.

Validation for each of the data exchanges may be time consuming. Typical issues arising during this critical task include synchronization across the data sets (all extracts need to reflect the same moment in time), incompatibility across drug databases, accounting for medical supplies or non-billable items, gaps in the provider database, and missing or incomplete data required to construct the patient’s clinical history. Even if you are using industry standard file layouts, plan on the same data exchange being performed multiple times until both sides are confident of the quality and have a full understanding of the gaps.

Under certain conditions—particularly when the incumbent pharmacy is not prioritizing the transition—current and historical claim extracts may not be readily available to support a transition. Alternative data sources utilized for utilization reviews may include claims extracts supplied as remittances to invoiced amounts and annualized data contained in standard reports. As your specialty pharmacy is focused on delivering clinically effective programs for members, you will need to be flexible with the data you use in order to conduct utilization reviews prior to and during the transition process.

Your pharmacy work flow will also need to be reviewed and enhanced as needed to support the new book of business. The new plan may introduce different clinical protocols and prescription pathways that will need to be followed. This may require you to obtain additional information from patients and providers prior to dispensing.

In addition, as with any relationship, it’s all about communication. IT will need to support provider relations and the operations teams with relevant communication initiatives. Generally, communication with providers will occur multiple times prior to and during the transition. This communication will be created from information obtained from the data exchange. Introduction letters, patient registration information, and listings of impacted members serviced by the provider will be sent out prior to the transition.

Lastly, at the point of transition, providers will need to be notified of expiring prescriptions. This is critical for prescriptions where the final fill is dispensed by the incumbent. These Rxs may not be part of the open refill transfer file and new prescriptions will need to obtained from the provider to ensure that there is not a gap in the patients’ adherence. Communication activities such as these may require that dedicated telephone and fax lines be up and running well in advance of the “go live” date.

Member communication may include welcome packets, information concerning prescription pricing changes, the continuity of clinical programs, and/or the availability of additional clinical resources. As with the provider communication strategies mentioned, IT will need to provide data extracts linking historical patient, provider, and prescription fill history.

Throughout the transition process, the IT team will need to utilize a flexible approach and focus on quality results. This includes managing data exchanges, enabling clinical utilization reviews, implementing work flow improvements and assisting with focused communications strategies. The incumbent pharmacy may not be as attentive to your requirements, as you would like; however, you cannot let this impact the quality of the patient’s care and the payer’s experience with its new specialty pharmacy.


About the Author

Jim Maguire is the chief executive officer of BioMed Intelligence, Inc, a firm specializing in health care information technology support solutions. With more than 20 years of experience, Mr. Maguire was formerly the chief information officer of a top pharmacy benefit manager and also led information technology operations at a leading specialty pharmacy. He can be reached at 347-847-3570; jmaguire@ biomed-intelligence.com; and www.biomedintelligence. com.

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