Empowering Patient Care: Transforming Coverage Decisions for Better Outcomes

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Overview

Pharmacy Benefit Management (PBM) companies establish coverage rules for their clients, such as healthcare insurance providers. These rules determine a member’s eligibility for medication coverage when a request is made. The coverage review process is a critical component of Evernorth’s Reviews and Appeals business. Pharmacists use this process to create prior authorization cases, assessing the eligibility of specific medications for individual patients.

Goal

The project aimed to modernize two key systems:

  1. The Authorization Criteria Management System, which defines criteria for prior authorization reviews to determine eligibility for benefit overrides.
  2. The Prior Authorization Management System, which supports the addition, updating, and review of prior authorizations.

Challenge

Modernizing the client’s Administrative Toolkit and Coverage360 portals posed a set of challenges, especially the migration from a legacy system to a new platform. Beyond transferring data, managing attachments—a seemingly minor but complex detail—emerged as a significant hurdle. Addressing this challenge required innovation and a tailored approach to ensure precision and alignment with the new system. Through collaborative efforts and strategic execution, the platform was successfully transformed, providing a foundation for improved efficiency and enhanced user experiences.

Solution

Sky Solutions leveraged Pega to develop a comprehensive solution that modernized the Administrative Toolkit and Coverage360 portals. These enhancements enabled Case Managers and Case Workers to efficiently manage prior authorization cases. Some of the solution highlights include:

  • Unified Platform: Development of a unified platform to streamline operations related to criteria setup, prior authorizations, and case management processes.
  • Specialized Portals: Creation of specialized portals for the Enrollment, Criteria, and Letters Teams.
  • Robust Tracking: Integration of robust tracking capabilities to manage prior authorizations, including primary requests and appeals, enhancing oversight and responsiveness.
  • Automated Reporting: Enabling users to request and receive reports based on specific criteria, delivered directly to their email.
  • Seamless Subsystems: Integration of various subsystems to create, update, and track cases, with FileNet integration for sending and receiving attachments.
  • Bulk Enrollment and Exporting: Bulk enrollment of clients and criteria data through Excel imports, as well as bulk exporting of criteria data to PDF.
  • Improved Communication: Implementation of a system for outbound communications regarding case decisions, improving transparency and service delivery for clients.

This modernization effort was designed to enhance operational efficiency, improve client interactions, and streamline the prior authorization management process.

Technologies/Methodologies

  • Pega
  • FileNet
  • Low-code/No-code

Outcome

  • The Administrative Toolkit streamlined the client enrollment process, leading to a significant increase in new client enrollments within the first quarter of implementation.
  • The setup of criteria data and templates for outbound communication was optimized, resulting in a more efficient workflow.
  • Coverage360 reduced the turnaround time (TAT) for processing critical prior authorizations (PAs) to just 24 hours, ensuring faster service for high-priority cases.
  • Non-critical PA cases achieved a TAT of 72 hours, enhancing timely processing and improving client satisfaction.

These improvements resulted in a streamlined system, significantly boosting client engagement and operational efficiency.
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