PBMs ahead of health plans in automation efforts
A new survey tracks industry efforts to streamline administrative tasks--and cut costs from the health care system.
Pharmacy benefit managers (PBMs) are ahead of health plans in automating key administrative workflows, according to the first CAQH Pharmacy Services Index — a report that examines the levels of automation for three common administrative transactions.
“The initial data indicates that PBM administrative transactions are generally more automated than similar medical transactions, but this is just the first step,” April Todd, CAQH’s senior vice president for CORE and Explorations, said in a statement. “Based on these preliminary findings, we hope to expand our research to include providers and additional transactions to understand the differences in how administrative functions are conducted and to pinpoint opportunities for greater automation.”
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Data for the 2019 CAQH Pharmacy Services Index was contributed by PBMs representing 65% of all covered lives in the United States and presents findings on the following three transaction types:
- Eligibility and benefit verification: PBMs conduct 94% of eligibility and benefit verifications electronically. This high level of automation is likely because eligibility is verified during the real-time adjudication process for pharmacy claims, according to CAQH.
- Electronic prior authorization (ePA): Three-quarters of pharmacy prior-authorizations are fully electronic and use the National Council for Prescription Drug Programs SCRIPT electronic standard for prior authorizations and attachments.
- Claim submission: This is the most widely adopted fully electronic transaction, reported at nearly 100% for both PBMs (99%) and medical plans (96%).
While the disparities in eligibility and benefit verification and electronic prior authorization might be due to several factors — including volume, workflows, and standards — this data suggests there are opportunities for greater automation across the industry, according to CAQH officials.
Next, CAQH (a non-profit alliance of health plans and related associations) expects to work with PBMs, providers, and other partners in the pharmacy space to collect information on the cost of performing administrative transactions, the return on investment of automation, and differences in the medical and pharmacy workflows.
“Administrative complexity drains $350 billion from our health care system every year, and incremental increases in automation can significantly reduce these costs,” Todd said.
Read the 2019 CAQH Pharmacy Services Index, which expands on the alliance’s annual CAQH Index tracking automation in the medical and dental industries.
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