Specialty Pharmacy Work Flow Operations: Technological Considerations Overview

Specialty Pharmacy Times, October 2012, Volume 3, Issue 5

Technology can assist with back-end work flow operations, including screening, inventory management, packing, shipping, billing, and other crucial processes.

Technology can assist with back-end work flow operations, including screening, inventory management, packing, shipping, billing, and other crucial processes.

Successful technology solutions supporting key specialty pharmacy work flow operations must account for the interdependencies between work flow operations as well as the potential overlapping within specific operations. In support of this effort, the technology solution must also be configured for data and operational drivers as well as reporting requirements throughout each stage within the work flow operation. In Part 1 of this 2-part series (Specialty Pharmacy Times, June 2012), technological considerations for “front-end” work flow operations were reviewed (enrollment/ patient intake, insurance verification, order/item entry, prior authorization, and scheduling). In this article, technology considerations for the key “back-end” specialty pharmacy work flow operations will be discussed.

Screening

Once orders are placed, technology considerations supporting screening work flow operations will need to be considered. In an effort to streamline the screening work flow operation, technology solutions should automate screening for drug-to-drug interactions, duplicate therapy, and dose checking through the use of third-party database files. In addition, specific screening work flows should be in place to support activities based on screening results. Screening results should be reportable as well as actionable, specifically for failed results. Failed results should be configured as an operational driver with supporting review materials available for reference or to trigger applicable outreach activities.

Adjudication/Rejects

Of considerable importance to specialty pharmacy work flow operations will be its adjudication operations. Orders available for adjudication may be priced against pricing available from multiple third-party sources. For example, drug pricing could be based on the pharmacy’s acquisition cost or a specific price list. As a result, functionality should be in place to support pricing beyond traditional sources such as Medi-Span and First Databank. In order to ensure that prices are accurate and up-to-date, technology solutions will need to be configured to support receipt and storage of current daily and weekly files. Historical files should also be maintained and readily retrievable to support reprocessing and auditing activities.

Once the claim has been priced, if expected to be paid by a third-party payer or pharmacy benefit manager (PBM), technology solutions must be connected to payers through a switch service provider (ie, Emdeon or Relay Health) to process the claim. Specialty pharmacies may also employ additional services from switch service providers such as pre/post edit services and prior authorization management.

Many pharmacy management systems allow for the submission of a “test claim.” Test claims represent transactions used to confirm patient eligibility and the existence of any coverage restrictions and/or requirements (ie, prior authorization, step therapy, etc). While test claims are useful, control procedures should be in place to minimize potential processing errors if not correctly reversed. Reporting considerations should also be in place during this work flow as the tracking of each transaction will not only be critical to ensure standard operating procedures are followed (ie, reversing trial claims), but will also be expected to support internal and external audits.

Dispensing

Of significant importance to specialty pharmacies is management of their inventory. Whether managing single or multiple pharmacy locations, real-time and accurate visibility into the pharmacy’s inventory will be critical to dispensing work flow operations. As a result, technology solutions supporting dispensing must be integrated in real time with adjudication and inventory, regardless of whether the technology solution supports this work flow or interfaces with an external dispensing system. While automated dispensing could be its own article, here are some technical points for consideration:

  • In the specialty arena, automated dispensing typically will be used for highvolume oral tablets and capsules.
  • Understand the software interface and its limitations. Some of the automated dispensing devices are not bilateral in communication and are only capable of receiving orders; they may not communicate the dispensing status of the order back to the pharmacy management system (PMS).
  • Bar code—enabled processes will speed up replenishment time.
  • Leverage inventory and replenishment technologies should be provided with the dispensing device as much as possible.

Technology solutions supporting the dispensing work flow must also be configured to support operational drivers for associated printed materials. While invoices may be defaulted to print with each prescription, additional reference materials (ie, new enrollment welcome kits, patient education leaflets, etc) must also be configured to support the particular prescription and any associated patient programs. In an effort to support interdependencies with other work flows, technology solutions should not only provide immediate access to all materials sent to the patient, but also the ability to view the printed materials. Printed materials must also be tracked and reportable to support compliance and auditing activities.

Quality Assurance

The quality assurance work flow is primarily performed to ensure that the correct medication is being sent to the correct patient with the correct patient educational materials. Quality assurance work flow operations will also review non-clinical components within the order, such as the billing invoice/receipt and enrollment packets that are distributed to the patient.

Technology solutions supporting the quality assurance work flow should not only support the review of the dispensed medication utilizing drug imaging, but also support the ability to flag an order with errors. Flagged orders should be configured to trigger subsequent data (ie, adjust/re-adjust inventory) and operational drivers (ie, “un”-dispense and “re”-dispense the order) based on identified errors. The ability to track the order up to and throughout the quality assurance work flow will be of critical importance to support internal and external reporting requirements related to clinical reviews.

Packing

Technology solutions supporting the packing work flow should be configured to address the multiple shipping methods available for the medication(s) and associated supplies within the order. Interdependencies with the shipping method and patient “needed by” date should also be considered, as the packing method selected should coordinate with the delivery method and transportation time for the medication and associated supplies. Technology solutions supporting the packing work flow should be configured to adjust requirements based on recipient (ie, patient, provider, etc) requests and delivery availability (ie, holidays). As a result, logical sequencing for selecting the appropriate dispensing methods should be in place to ensure proper and safe transportation of specialty medications, particularly refrigerated products, and associated supplies.

Shipping

Whether internally managed or contracted out, shipping work flow operations must be coordinated with the scheduling and dispensing work flows. Technology solutions will typically interface with third-party providers’ shipping applications (ie, Fed-Ex, Pitney Bowes, UPS, etc) to coordinate the delivery of the specialty medication to the patient/provider. While technology systems will record the tracking number, weight, and costs associated with the shipment, successful technology systems will also support delivery tracking. Reporting considerations should also be in place during this work flow, as the tracking of each order through delivery will be critical in supporting internal and external reporting on compliance with patient “needed by” date.

Recently, many shippers added the actual signature image to the data available through the tracking interface. This will enable the display of the recipient’s signature from within the PMS, a value add when researching or confirming delivery with a patient or provider.

Billing

The final work flow—billing—is of significant importance when managing your accounts payable (AP) and accounts receivable (AR) operations. Successful technology solutions supporting the adjudication process should also provide systematic tracking and billing for paper claims. Considerations should be in place for supporting both electronic (ie, 835s) and paper form remittance submissions associated with paper claims processing. Medical billing may be more complex, requiring conversion from NDC to JCODE or HCPC. This may also require a conversion of units. These conversions can be tricky and some may be payer specific.

Regarding AR operations, real-time interfaces with third-party payment processors will also be necessary to accept credit card and check payments from patients. Technology solutions should also support manual and systematic writeoffs and adjustments to outstanding balances triggered by payment data drivers.

Whether managing “front-end” or “back-end” work flow operations, it is clear that successful technology solutions will support the multiple interdependencies between work flow operations as well as the associated reporting requirements within each work flow. Data and operational drivers should also be configured in a manner to streamline work flow processes, eliminate redundant data entry, and support patient communication activities.

While technology considerations for the key specialty pharmacy work flow operations are addressed in this article, it is important to note that a full assessment of the specialty pharmacy’s technology and custom work flow requirements will be necessary to ensure that successful technology solutions truly deliver functionality designed to minimize the unique challenges within the specialty pharmacy industry.

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; www.biomed-intelligence.com.