Work Flow Operations Overview: Part I

Specialty Pharmacy TimesJune 2012
Volume 3
Issue 3

Technology solutions are commonly deployed to support key work flow operations and the increasing demands of reporting requirements. Here's the first installment of a 2-part article that examines important technological considerations in the specialty pharmacy work flow.

Technology solutions are commonly deployed to support key work flow operations and the increasing demands of reporting requirements. Here's the first installment of a 2-part article that examines important technological considerations in the specialty pharmacy work flow.

Specialty pharmacy work flow operations rely heavily on processes that support complex interactions among patients, providers, and payers. Technology solutions are commonly deployed to support 1 or more key work flow operations while introducing cost-effective and -efficient processes. Of equal importance is the technology solution’s ability to support the increasing demand of manufacturer and payer reporting requirements throughout each stage within the work flow operation. As a result, successful technologies will need to ensure specialty pharmacies achieve their desired state while extracting the maximum value on an ongoing basis. This 2-part article reviews the technological considerations for 12 key specialty pharmacy work flow operations (see Specialty Pharmacy Times, August 2012 issue, for Part 2).

Specialty pharmacy work flow operations are typically referred to as either “front-end” or “back-end” processes. Front-end processes encompass enrollment, insurance verification, order entry, and adjudication reject management activities. Back-end processes encompass post-adjudication activities such as dispensing, quality assurance reviews, and shipping. While front-end and back-end processes may appear linear as defined, successful technologies will support the interdependencies between each work flow operation as well as the potential overlapping within specific work flow operations.

Work flow operations can determine the processing sequence for an order as well as dictate certain activities that impact the order. Two key components are essential throughout each work flow operation—Data Drivers and Operational Drivers. Data Drivers incorporate information that is obtained from and provided to patients, providers, and payers. Examples of data drivers include information required to initiate enrollment and adjudication activities as well as information necessary to support manufacturers’ and payers’ reporting requirements. Data drivers may also be strategically utilized to support diseasespecific therapy management activities (ie, patient assessments) and manage outreach efforts with patients and providers (ie, addressing multiple requirements during first outreach effort).

Operational Drivers comprise unique procedures to be deployed based on triggered events. Examples of operational drivers include proactively initiating a prior authorization based on a profiled medication and provisioning partial fills on the first fill of certain drugs to ensure no adverse reactions are present. Operational drivers may also be utilized to manage the unique shipping and storage requirements associated with dispensing certain drugs. As a result, specialty pharmacies will need to ensure the work flow operations within their Pharmacy Management Systems (PMS) are configurable by data and operational drivers specific to payer, disease state, and drug considerations.

Enrollment/Patient Intake

Enrollment information can be received at the pharmacy in various forms from multiple sources. As a result, the technology that supports the enrollment process will need to ensure receipt capabilities from physician/hospital faxed forms, payer electronic feeds, and third party providers via telephone calls and e-mails. Technology supporting the enrollment process will also need to support enrollments initiated from electronic prescriptions. Regardless of input form or source, electronic enrollments should seamlessly import into your pharmacy management system and work flow operations, eliminating manual entry errors and ensuring expedited processing. In addition, successful technologies will need to track the originating source and associated source identifiers for the patient throughout each work flow operation as well as ensure that information submitted back to the originating source contains the particular identifiers that are unique to that source.

Once enrollment information has been captured, successful technologies should also be able to quickly assess the missing information based on work flow drivers and payer, disease state, and drug considerations. Identification of missing critical data elements affecting enrollment and future work flow operations should be addressed immediately in order to avoid blockage during current and future work flow operations. Consider multiple ways to obtain missing information, including establishing strategic points where various types of data can be obtained during regular interactions with patient and providers.

Additional enrollment technical considerations include:

  • Capture missing standard demographics and provider information (ie, identifying correct disease states)
  • Capture multiple addresses (ie, home address, shipping address, and nurse/ caregiver information as appropriate)
  • Capture full contact information including e-mail addresses for future communications
  • Support medication profiling data points including dates and relevant updates on subsequent events (ie, orders, calls, etc)
  • Support multiple opt-out options for automated phone calls and events

Insurance Verification

In an effort to expedite the delivery of medications to patients, pharmacies will typically attempt an adjudication transaction based on the information received during the enrollment work flow operation. Performing automated insurance verification at this point is critical to work flow efficiency, as information obtained from and confirmed by third party services can help to ensure claims will process successfully. Pharmacy management systems should not only support automated insurance verification capabilities from third parties but also perform independent verification of formulary and eligibility information based on stored formulary files and coordination of benefits records from alternate payers. Based on the responses received from adjudications following enrollment, PMSs should also be configured to trigger appropriate work flow drivers for multiple subsequent work flow operations based on reject reason codes.

Initial outreach efforts to patients and providers can be strategically managed between the enrollment and insurance verification work flow operations to ensure all necessary information is obtained during key interactions. Successful technologies should also support proactive identification of potential factors affecting successful claim processing, as a patient’s inability to pay for prescribed specialty medications is one of the top reasons for not filling a prescription. Due to the nature of specialty medications, not filling a prescription could cause significant risks to patient health and potential risk for increased health care costs. As a result, utilizing technology to proactively identify patient deductible and copay information from paid claims can lead to financial assistance and coordination of benefit discussions with patients. If insurance verification work flow is properly designed, it should not only support successful claim adjudication but also improve service levels, patient compliance, and medication adherence with patients. Additional insurance verification technical considerations include:

  • Confirm plan information is entered correctly
  • Confirm formulary coverage (trial adjudication)
  • Confirm deductible and copay information
  • Capture all possible insurance information (ie, PAP, COBs, etc)
  • Capture all Medicare required inputs for claims submissions and Prior Authorizations
  • Confirm billing override information

Order/Item Entry

Pharmacies may automatically create orders and order supplemental items (ie, supplies) utilizing information from enrollment and insurance verification work flows as well as information based on a pharmacy’s standard operating procedure for certain drugs. Successful technologies for order entry work flow should support the association of prescription images received from a provider to manual entries. Systems should also be configured to retrieve incoming faxes and direct them into specific work flow queues to help properly prioritize and manage work flow. Additional items should be automatically added to orders based on scheduled parameters for a prescription (ie, kits, consent forms, and surveys on all and/or certain orders) and supplemental items based on the route of administration and shipping methodology required for the order. Effective management of these added items should be supported by an interactive maintenance screen with recommended and mandatory selections. This is a critical portion of proper Risk Evaluation Mitigation Strategies (REMS) management. Successful technologies should also be configured to support supplemental items driven by drug selection and payer/pharmacy outreach communication driven by drug selection and/or order entry.

Additional Order/Item Entry technical considerations include:

  • Rx Add/Edit functionality
  • Plan, Physician, Formulary lookup for ordering supplemental items
  • Medication profile management with status tracking
  • Rx Images
  • REMS-mandated information

Prior Authorization

Certain payers may require a Prior Authorization for certain drugs. Successful technologies should be configured to associate Prior Authorizations at payer/drug level in order to begin processing during the enrollment work flow operation. Successful technologies should also identify the sources of information required by payer to effectively manage communication with various sources. Work flow operations should be configured to submit rejected Prior Authorization back to insurance verification work flow operations. Bar codes on outbound faxes of Prior Authorization requests will assist in efficient reconciliation of data received from providers when managing your Prior Authorization queue.


Coordinating the delivery of drugs with the patient and provider is a critical work flow. Without ensuring proper delivery, patients may not receive the necessary medication in a timely manner. As a result, successful technologies should manage overnight packaging requirements and shipping restriction days in accordance with certain drug parameters. Maintenance screens can provide quick checklists to ensure packaging and shipping requirements are managed correctly. Refills should be proactively managed to streamline turnaround time and should be supported by monitors and alerts within the technology.

Final Thought

Regardless of whether your solution is purchased or developed, specialty pharmacies will need to ensure that work flow operations are properly managed within their chosen system and that the system is properly configured with reporting capabilities to support multiple reporting and extract requirements within each work flow. Careful consideration should be made to account for the interdependencies between and overlapping within the front-end and back-end processes.


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@biomedintelligence. com; www.biomedintelligence. com.

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