Initial Challenge

A leading Pharmacy Benefit Manager (PBM) faced significant challenges in managing their prescription case review process. The PBM initially projected a substantial team size, which included the need to recruit, hire, and onboard a significant number of non-clinical support staff, pharmacists, and physicians. These estimates were grounded in their internal processes and the anticipated workload.

UMS Solution

To address these challenges, the PBM partnered with ExamWorks UM Strategies (UMS) to optimize their case review process. UMS started with a smaller, more manageable cohort to understand the client's workflows and expectations. This flexible approach met the client’s initial benchmarks. As case volume grew, UMS expanded the cohort and identified key areas for improvement. By the time the UMS cohort reached 60% of the PBM's original estimate, UMS was already 30% more productive than the PBM's internal team.

Process Improvements

UMS conducted a Lean-based process improvement project to enhance the efficiency of the case review process. Our pharmacists meticulously analyzed the steps involved in the review process and identified opportunities for optimization.

Key improvements included:

  • Template Creation: Developing standardized templates and workflows for the top 10 most frequently reviewed drugs. This reduced time spent on repetitive tasks and ensured consistency in the review process.
  • Workflow Standardization: Establishing clear standards for the most common review types, which streamlined the process and improved productivity.

Performance Metrics

The partnership with UMS yielded impressive results:

  • Productivity: UMS achieved a 30% increase in productivity over the PBM's internal team and alternative review solutions. This productivity was achieved with 60% of the estimated pharmacists, physicians, and non-clinical support staff.
  • Volume Efficiency: UMS’s services adapt to volume fluctuations, quickly responding to increases in case volume while maintaining high performance metrics. We consistently meet 100% of productivity benchmarks for both Commercial and Medicare cases.

Enhancing Efficiency In Prescription Medication Prior Authorization Reviews

Performance Metrics cont.

  • Turnaround Times: UMS ensures a 99.8% and higher turnaround time success rate for Urgent and Standard, Commercial, and Medicare Part D cases.
  • Decision Quality: UMS consistently meets 99.5% and above decision quality requirements for Commercial and Medicare Part D cases.
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Key Takeaways

The partnership with UMS has provided several direct benefits to the PBM:

  1. Cost Efficiency: By managing the recruitment and onboarding of the entire team, UMS has taken on the risk and cost associated with staffing fluctuations. This has significantly reduced the PBM’s operational expenses.
  2. Scalability: UMS’s ability to quickly adapt to increased workloads ensures that the PBM can handle new lines of business without the need for extensive internal hiring and training.
  3. Consistent Quality: The high-quality audit scores and on-time performance have enhanced the PBM’s reputation and client satisfaction.

Conclusion

The collaboration between the PBM and ExamWorks UM Strategies has been a resounding success. By starting with a smaller cohort and implementing Lean-based process improvements, UMS has not only increased productivity but also maintained exceptional quality standards. The flexibility and scalability of UMS’s services have provided the PBM with a reliable and cost-effective solution to manage their prescription case review work, even in the face of unexpected volume increases. This partnership exemplifies how strategic outsourcing and process optimization can drive significant operational improvements and business growth.