Specialty pharmaceuticals have contributed substantially to the rise in the nation’s drug costs over the last several years, and these costs are projected to continue increasing by 9% annually. In addition, whether a drug is covered under the medical or the pharmacy benefit can lead to substantial variation in management. The prevalent “buy & bill” model is unmanaged, expensive and in need of replacement by a value-based & outcomes-driven model.
nirvanaHealth Specialty Drug Management, powered by Aria, provides a streamlined 10-step process to convert “buy & bill” to a value-based and outcomes-driven specialty management model, while avoiding disruption to physician workflow or additional effort for the plan sponsor to reconcile medical and pharmacy claims.
Conventionally, physicians buy from their preferred vendors and pharmacies, then bill the plan sponsor for the cost of the drug and other fees, such administrative fees. In nirvanaHealth’s “Value-Based & Outcome-Driven” model, when a patient visits a prescriber at the point of care to obtain a specialty medication, the physician submits and obtains a prior authorization (PA) from nirvanaHealth through SureScripts. Upon successful approval of the PA, the physician can submit the prescription through his preferred medium (fax, voice call, mail, EMR-ePA, Web Portal, etc.). nirvanaHealth’s specialty pharmacy then receives the prescriptions and uses the inbuilt logic to discern if the prescription needs to be adjudicated as a medical claim or pharmacy claim. After adjudicating the claim, nirvanaHealth delivers the drug to either the patient’s residence or to the physician’s workplace. In the latter case, the patient then re-visits the clinic to have the medication administered.
When it comes to the payments for the providers, nirvanaHealth submits separate invoices for medical claims and pharmacy claims, collects this balance from the plan sponsor, and then pays the specialty pharmacy as per the agreed-upon rates. The prescriber then submits the medical claims with line items delineated (such as administrative fee, nurse’s time, etc.) to the plan sponsor. In these line items, there will be a line item for drug cost, which will be submitted complete with the drug’s corresponding j-code and a zero-value for drug cost.
Our Specialty Drug Management services are comprised of 3 major phases: Onboarding, Diagnosis & Administration, and Continuing Care & Monitoring. Immediately after contracting, plan onboarding begins.
nirvanaHealth leverages all available historical data – medical, pharmacy, and lab claims– to deliver an optimal specialty formulary that produces superior clinical and financial outcomes for the plan sponsor and members. Aria Formulary Management is a highly customizable and intuitive platform, with the ability to provide gap analysis to identify areas of clinical and financial improvement; to support multiple third-party drug databases and classification systems; to configure drug lists, tiers, and utilization management rules; to streamline formulary change management processes for efficient decision-making and implementation; to analyze drug utilization trends; and to harness built-in CMS rules and guidelines.
Our Specialty Network Management services include extensive negotiations with manufacturers and pharmacies to create a narrow network consisting of nirvanaHealth’s Specialty pharmacy plus a small group of preferred specialty pharmacies. This process ensures that all treatments result in the lowest possible cost for the plan, and the best possible care for the patient.
In order to provide effective and efficient care plans for patients with illnesses that require specialty pharmaceuticals, medical professionals such as physicians, nurses, at-home care specialists, and other caregivers must be able to communicate on one unified platform. Care stakeholders including prescribers, pharmacists, patients, and clinical/pharmacy staff of payers are often frustrated with being required to access too many portals and hard copy reports to obtain a comprehensive view of a patient’s health, current/past care activities, actionable drug utilization review (DUR) information, comprehensive pharmacy/medical patient profiles, and real-time alerts.
The nirvanaHealth solution to this problem is to educate the caregivers on the capabilities of nirvanaHealth’s Aria platform and its ability to deliver actionable information into care stakeholders’ respective workflows at every stage of the care continuum. By providing the right information into the hands of both service providers and members, effective cost management and service excellence can be maximized. The ability to allow a physician to access programs and services with minimal disruption to their normal practice routines is the destination of the PBM market’s evolutionary path. Of equal importance is the need to continue to create tools are focused on meeting the unique needs of each patient.
nirvanaHealth’s vision is to educate prescribers, caregivers, and patients on claim submission, PA submission, specialty bundled episode risk management services, and all the other features of our Aria-powered Specialty Drug Management.
Our Specialty Drug Management service provides comprehensive utilization management programs created to ensure all therapies meet P&T protocols such as prior authorization, step therapy, quantity limits, route of administration, and place of administration. Our Aria platform leverages industry guidelines/ADE indications and therein delivers this information at Point of Care and Point of Sale.
As patients begin visiting or calling their physicians, specialty medications are prescribed. Most specialty medications require a prior authorization to be successfully processed at a pharmacy. nirvanaHealth comprehensively manages these prior authorizations, delivering a collaborative, rule-based, and user-configurable Aria Utilization Management module. Aria leverages sound clinical protocols and pharmacy, medical, and lab claims to derive an evidence-based decision. This ensures that each authorization determination is based upon medical necessity, proper prescriber utilization, reduction of ADEs, and evidence-based prescribing patterns.
nirvanaHealth facilitates the acquisition of specialty drugs from our specialty pharmacy network. These preferred specialty pharmacies offer best-in-market pricing, leveraging our relationships with over 65,000 pharmacies nationally.
Through Aria Claims Adjudication, nirvanaHealth delivers highly flexible, scalable, and automated core claims processing services. Built from the ground up, this system logic determines if the claim should be adjudicated as a medical or pharmacy claim, while offering unlimited flexibility to design benefits, formularies, pricing, pharmacy network contracts, and compliance changes through rule-based user configurable modules. nirvanaHealth’s fully integrated system of record allows for the derivation of actionable intelligence, which can be delivered at the point of care, point of sale, to members through our mobile application, and to the plan’s clinical and pharmacy staff.
For each specialty patient, nirvanaHealth’s Aria platform generates a custom, concise, and coherent care action plan that is assigned to a care manager. Using comprehensive care protocols, care managers, caretakers, and patients work collaboratively to achieve optimal adherence and to monitor adverse drug events and patient health outcomes. Towards the end of the care management program, patients are screened against concurrent drug monitoring criteria and eligible patients are enrolled into MTM and other relevant programs. These program interactions, outcomes, and other related information are shared with all stakeholders.
As part of the billing cycle, the prescriber submits the claims to the plan sponsor for administration services only. nirvanaHealth invoices the plan sponsors separately for medical and pharmacy claims at the pre-negotiated rate. nirvanaHealth then receives the medical claim from the plan sponsor, performs the reconciliation of pharmacy and medical claims, and then sends the completed claim back to the plan sponsor. All this activity is accomplished with no additional effort to the plan sponsor.
Financial results and health outcomes are measured against predefined metrics to validate and improve our Aria-driven Specialty Drug Management program.
Since 2013, the RxAdvance team has been dedicated to disrupting the healthcare industry, specifically in pharmacy benefit management. After 3 years of development, we went live with our first client in 2016 and delivered groundbreaking pharmacy benefit management services. Now that we have proven success year-after-year, we have decided to expand our impact beyond just the PBM industry—onto the payer industry. These two industries alone control the majority of the healthcare spend in the United States, including the $900+ billion of waste generated annually. With our expansion into a new portion of the industry, we have outgrown the RxAdvance name, since it does not accurately capture the scope of our healthcare reach and mission. We are excited to announce our new name and brand—nirvanaHealth. The RxAdvance name has served us well for many years and will continue to do so under nirvanaHealth.