DSP
Case Studies

High Level of Customization

Client: Workers Comp

High Level of Customization

Challenge:

This client, the local universal worker’s compensation organization in Puerto Rico, identified the need for a front-end pharmacy system for its 20 internal pharmacies that would provide adequate dispensation and inventory records and controls, and a PBM component to deploy clinical, quality, and utilization management tools. The project’s specifications called for a very high level of customization, way beyond the normal pharmacy benefits administration.

How We Build It:

Eligibility

  • Handling and/or generating ad-hoc, incident-based eligibility at the point of service
  • Consolidating multiple cases into a single patient record
  • Centralizing all patient information received from different pharmacies and other internal and external systems and providers to maintain an up-to-date patient profile
  • Providing for various patient identifiers including case number, patient name and address, date of birth, SSN, as available to avoid patient identification mistakes

Integration

  • Fully integrating the front-end pharmacy system with the PBM to create a seamless environment
  • Including hospital inpatient pharmacy dispensation, including IV fluids and solutions into the full cycle, from pharmacy front-end through the PBM approval processes
  • Integrating inpatient and outpatient drug history
  • Integrating all existing provider/prescriber, pharmacist and pharmacy technician records including credentials and expiration dates

Customization

  • Deploying all tools necessary to manage drug purchases, inventory control, distribution logistic, utilization and fraud, waste and abuse controls
  • Providing capabilities to coordinate benefits for those claimants with employer-sponsored health plans, avoiding further duplication of drug system capable of keeping only one medication record for the same patient with multiple case numbers as well as one medication record for out-patient and in-patient environments
  • Front-end pharmacy able to integrate with the PBM eligibility system to be able to adjudicate pharmacy claims as soon as the member is eligible
  • Only one central network system for all the pharmacies to prevent duplicate member records and duplicity of pharmacy services
  • The front-end pharmacy system had to be the same for out-patient and in-patient records, thus improving the continuity of pharmacy services when members transition from the hospital to the community allowing for an accurate medication reconciliation between settings
  • System administers drug purchases, inventory control, distribution logistic, utilization controls and  fraud, waste and abuse controls

End Result:

Through PharmPix’s PBM services, the client is now able to coordinate pharmacy benefits with the Puerto Rico employers it serves. This successful implementation was completed in just 7 months.