Drug Channels: Shifting Strategies: Tackling Patient Support Program Reverification

Today’s guest post comes from Jan Nielsen, Patient Solutions Division President at AssistRx.

Jan discusses the challenges facing life sciences organizations’ patient support program reverification processes. Jan then highlights how the right vendor can help overcome these challenges for both pharmacy and medical benefit products. She offers real-world examples how of AssistRx implements these solutions for clients.

To learn more about AssistRx’s solutions for medical benefit products, read their latest case study: eMedical Benefit Verification: Improving Speed to Therapy and Patient & HCP Experiences.

Read on for Jan’s insights.

Shifting Strategies: Tackling Patient Support Program Reverification
By Jan Nielsen, Patient Solutions Division President at AssistRx

With the 2024-2025 annual reverification season rapidly approaching, life sciences organizations should be reassessing their patient support program (PSP) annual reverification performance. Coined “blizzard season” for its flurry of activity and new hires, annual reverification poses challenges like budget spikes and potential gaps in patient care.

Factors contributing to rising blizzard season challenges include:

Regulatory changes. Aspects of the Inflation Reduction Act (IRA) are expected to affect payer strategy, impacting life sciences organizations’ copay and patient assistance programs (PAPs).
Updates to coverage policies. Changes to payer utilization management strategies, such as prior authorization (PA) requirements, present new access hurdles. A study from Avalere spanning six years found that utilization management obstacles increased in the commercial market for all studied therapeutic areas.
Changes in insurance providers. In one study published in JAMA, one in five commercial insurance plan members disenroll each year, meaning patients may gain or lose coverage for their medications with their new insurer.

Considering these challenges, life sciences organization leaders should evaluate how PSP vendors adapt to a changing landscape through technology, talent off-ramps and specialty pharmaceutical expertise.

ANNUAL REVERIFICATION FOR PHARMACY BENEFIT PRODUCTS

Incorporating a tech-first approach to annual reverification for pharmacy benefit products should be relatively straightforward for PSP vendors. Unlike medical benefit products, patient-specific pharmacy benefit information is largely digitally accessible, enabling PSP vendors to collect coverage information. In combination with e-income verification, a tech-first approach to benefit verification (BV) and PAP eligibility shifts FTE manual work to digital and automates steps completed in the background.

For one AssistRx client leveraging our Advanced Benefit Verification (ABV) and eIncome Verification solutions to automate its PAP annual reverification, we converted more than 115 patients to commercial product, garnering roughly $16M in recaptured revenue.

ANNUAL REVERIFICATION FOR MEDICAL BENEFIT PRODUCTS

Medical benefit information is less digitally accessible than its pharmacy counterpart, making real-time, accurate coverage results harder to deliver. However, innovative PSP vendors are moving the medical benefit market forward. Although some vendors still use an FTE model, others use historical claims, artificial intelligence (AI) or direct connectivity with payers. Advanced medical benefit offerings are multifaceted, using two or more of the above approaches. The most advanced—and rare—solutions are multifaceted and multi-threaded, meaning they have direct connectivity to multiple data sources to ensure redundancy.

AssistRx’s multifaceted, multi-threaded eMedical Benefit Verification (eMedBV) solution leverages a three-pronged approach. eMedBV first uses direct connectivity with payers to return J-code specific coverage information in under 20 seconds for 70% patient inquiries, followed by AI-powered payer outreach, then offramps to talent. These medical benefit experts use already gathered data to swiftly collect remaining information.

For one client manufacturing four medical benefit products, AssistRx’s eMedBV solution leveraged direct payer connectivity to return comprehensive medical benefit coverage information in seconds, accelerating speed to therapy by 50%. For another client’s medical benefit product, AssistRx completed reverification for 32,000 patients in five weeks.

For medical benefit products requiring PA re-authorization, AssistRx uses a multifaceted Advanced Prior Authorization (APA) solution, featuring direct payer connectivity, a continuously maintained digital PA library and talent offramp.

STRATEGIC UTILIZATION OF TALENT FOR ANNUAL REVERIFICATION

Many specialty product PSPs need talent intervention to help patients and HCPs navigate today’s complex healthcare environment. Strategic utilization of knowledgeable, empathetic talent may always be required to step in when technology goes as far as it can.

For example, PSPs may need teams specializing in alternative coverage options, such as Medicare Low Income Subsidy (LIS) and third-party charitable foundations. One AssistRx client with a high Medicare population identified $12.9M in third-party charitable funding over the life of the program and supported 89% patients receiving funding in one year.

IRA’S IMPACT ON ANNUAL REVERIFICATION

IRA drug pricing reforms introduced several new factors likely to impact PAPs. To recoup revenue lost by IRA reforms, payers will look to shifting cost onto commercial patients. They’ll also further initiatives like specialty carveouts, which frequently make commercially covered patients appear uninsured. The IRA also puts a cap on Medicare patients’ out-of-pocket (OOP) spending, causing patients to hit their OOP maximum earlier in the year.

This means current PAP eligibility requirements may cover commercial patients rendered uninsured/underinsured by specialty carveouts when they do have coverage, and requirements may cover Medicare patients who no longer need PAP services, as well.

Ahead of annual reverification, life sciences organizations should partner with a PSP vendor that deploys modular and configurable solutions – such as AssistRx’s ABV and eIncome Verification—capable of making swift changes to PAP eligibility criteria.

YOUR ANNUAL REVERIFICATION STRATEGY

With these factors in mind, selecting the right PSP vendor — one that delivers tech-first solutions that reduce manual processes and rapidly meet changing market dynamics — will be a crucial element to your annual reverification strategy. Choosing a partner that understands how to balance tech + talent based on your patient and HCP populations facilitates optimal program performance, improved treatment outcomes, and differentiated patient and HCP experiences.

Learn how AssistRx accelerates speed to therapy and delivers tech-first reverification solutions for medical benefit products in our latest case study, eMedical Benefit Verification: Improving Speed to Therapy and Patient & HCP Experiences.

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Friday, May 31, 2024

Shifting Strategies: Tackling Patient Support Program Reverification

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