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Obtaining specialty medication authorization has always been a challenge for healthcare providers and patients suffering 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 in treating chronic illnesses such as rheumatoid arthritis and specific gastro illnesses. Still, these treatment plans are, to put it lightly, expensive.  The extensive research supporting the medications and the cost of medical staff and equipment to administer the infusions makes the burden on the patient and the practice sometimes too much to bear.

What is a specialty drug?

There’s often confusion regarding specialty drugs and other types of medication you can pick up from your local pharmacy. Specialty 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 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 they receive the drug – if they can 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 are 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 specialty medical benefits and a general overview of how insurance determines coverage let’s discuss some of the additional challenges a patient and a practice face when navigating 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 pay nearly impossible to understand. To make matters even worse, the practice often feels obligated to help patients navigate 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 patients.
  4. Benefit Investigations and Prior Authorizations –  Lack of workflows and inefficiencies in workflow processes at the practice level can amplify barriers to treatment. Multiple manufacturers and insurance portals coupled with daunting manual processes for required Benefit Investigations and Prior Authorization requirements can 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 at risk. When the practice buys the product and cannot bill the patient due to an insurance hang-up, the practice has to foot a costly bill.

How eBlu Solutions Can Help

The challenges patients and practices face 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 how we can help? Give us a call, and let us show you how.

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