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Obtaining specialty medication authorization has always been a bit of challenge for healthcare providers and patients who suffer from chronic illnesses. Inefficiencies in workflows and the inaccessibility of information have become well known barriers to treatment for those who need it most. Infusion and intravenous (IV) therapy are extremely effective ways to treat chronic illnesses such as rheumatoid arthritis and specific gastro illnesses, but these treatment plans are, to put it lightly, expensive.  The extensive research that support the medications as well as the cost of medical staff and equipment to administer the infusions, makes the burden on both the patient and the practice, sometimes too much to bear.

What is a specialty drug?

There’s often confusion when it comes to specialty drugs and other types of medication that you can pick up from your local pharmacy. Speciality drugs fall into a completely different category as they are classified by insurance companies as high-cost, highly-complex and “high-touch”, meaning they require administration from a doctor or medical staff.  These drugs are administered through infusion or through the vein.

Typically, although not always,  a patient will be required by their insurance company to have exhausted all other forms of traditional treatment for their illness.  A specialty drug is  most often covered by insurance dependent upon where their receive the drug –  if they are able to take a pill or self-inject at home, it is most likely to be covered by the drug benefits of their insurance plan. If the patients is to travel to an infusion center or to their doctor’s office to have the drug administered for them, it is more than likely to be covered by their medical benefits.

Now that we have a general understanding of what speciality medical benefits are and a general overview of how insurance determines coverage, let’s discuss some of the additional challenges a patient and a practice face when trying to navigate down the path to a successful treatment plan.

 Struggles With Obtaining Speciality Medical Coverage

  1. Misunderstanding of Insurance Benefits – The patient has already been struggling with a chronic illness and is frustrated that other treatment plans simply haven’t worked. Insurance coverage can be very confusing –  legal jargon, benefit levels and additional nuances of coverage can sometimes make understanding what a patient will actually pay nearly impossible to understand. To make matters even worse, the practice often feels obligated to help the patient navigate through their benefits.
  2. Payer Denies Treatment – According to research, initial rejection rates are noticeably greater for specialty medications than conventional medications.
  3. Medical Records Reviews– Insurance companies often require a lengthy paper trail to showcase that the patient has exhausted all other less expensive treatment options. These reviews can take up to eight weeks in some cases and can cause frustrating treatment delays for patient.
  4. Benefit Investigations and Prior Authorizations –  Lack of workflows and inefficiencies in workflow processes at the practice level can amplify barriers to treatment. Multiple manufacturer and insurance portals coupled with daunting manual processes for required Benefit Investigations and Prior Authorization requirements can really drag out the treatment plan.
  5. Financial Risk – The financial risk for both the patient and the practice is escalated when it comes to specialty medication. Because of the hefty price tag of these medications, it’s not just the patient that is at risk. When the practice buys the product and is unable to bill the patient due to insurance hang up, the practice has to foot a costly bill.

How eBlu Solutions Can Help

The challenges that patients and practices hurdle when navigating through the sticky word of specialty medications are big and robust. Our goal at eBlu Solutions is to help make the process smoother and more efficient for everyone – from patients and practices to the manufacturers and payers that support them. Want to know about how we can help? Give us a call and let us show you how.