Doctors all reviewing a tablet computer

A specialty healthcare provider’s biggest challenge is reimbursement or the possibility of a claim being denied by a payer. While a practice’s financial loss can be stressful, they also face a potential strain on their relationship with their patient. Uncertainty and confusion around the benefits of a new drug, specifically a costly drug administered via IV, can cause hesitation in the patient and potential disruptions on the road to therapy.

It’s no doubt that medication infusion administration in a physician or provider’s office is a complex process. Well before treatment begins, several layers of the administration process must be performed. ​This process, known as ID to IV (identification to IV infusion), has real consequences if not performed promptly or accurately. Most notable is the time to treat the patient, which reflects the time from the physician’s decision to the treatment date. ​

The ID to IV process encompasses the end-to-end process of clearing a patient for infusion therapy treatment. This process begins with a series of steps: medical benefits investigation, benefits verification, prior authorization/pre-determination, and active monitoring throughout treatment. Each step in this process is critical to the successful reimbursement for services provided. Until patients are cleared for care and insurance approvals are received, providers often do not initiate infusion treatment due to the cost of these specialty drugs and the financial risk to the practice for these “buy and bill” medications.

In late 2021, tackled the complex workflow for buy-and-bill specialty medication products by creating this visual to help their readers better understand the process. If you haven’t had a chance to review it, take a minute to look through it. You’ll quickly see that the HCPs are responsible for:

  • Ordering and buying the product
  • Prescribing (and administering) treatment
  • Inventory
  • Submitting claims
  • Assisting patients with financial assistance
  • Collecting co-payments

Because of the complexity of IV to ID medications and their staggering expense, the insurance reimbursement process can be even more difficult. More than half of these drugs are often covered under medical benefits rather than the more typical pharmacy benefits that are easier to approve. Medical benefit investigation adds an even lengthier, more complex, more “hands in the pot” process because of the cost of the drugs. Receiving electronic prior authorization upon prescription for these benefits has been difficult in the industry and has led to significant care delays and treatment obstacles for patients. Quite frankly, completing the PA process is one of the most important functions of the entire ID to IV process and significantly influences the time to therapy for the patient and the time to reimburse for the practice.

Letting technology take over

Utilizing technology and allowing automated workflow to take over some of the tasks in the insurance approval process can eliminate a lot of this burden. The ID to IV process is largely manual and relies heavily on outdated communication methods such as multiple phone calls, faxes, emails, and manual tracking. Through IT advances, specifically software development and market research, it’s been found that many of the steps in the process can be automated, accelerating the speed to therapy with near-instant benefits investigation to start the process and cutting time to prior authorization by up to six weeks.

So how does it work?

Benefits investigation and prior authorization naturally lend themselves to digital solutions. Collecting necessary patient information and submitting needed forms to Hubs and payer portals digitally cuts many of the manual steps out of the process. Integrations built between touch points throughout the process allow technology to easily take over, eliminating practice personnel’s need for monotonous steps. Software such as eBlu Solutions allows BI’s and BV’s to return in 60 seconds or less for nearly 77% of the cases*. This “real-time response” allows the HCP and the patient to feel more secure in their decision-making regarding treatment so they can move forward with peace of mind for payment and reimbursement.

Additionally, such software can provide additional visibility and insights for stakeholders regarding reporting. Centralized platforms with data dashboards and PA tracking allow the HCP, manufacturers, and payers to better understand the patient journey and treatment adherence. Such transparency provides a unique gateway to further optimizing the healthcare ecosystem to ensure there are fewer obstacles for current and future patients.

Want to find out more? Let’s talk.

*Based on eBlu Solutions BI data YTD