CoverMyMeds Prior Authorization Software Solves Major Problem in Healthcare Industry

Photo by Kevin Payravi / Via Wikipedia.

Helping their 10 millionth patient and solving a headache in the healthcare industry, CoverMyMeds creates a software solution that eases the prior authorization process for prescriptions.

“To a pharmacy, prior authorization is probably the number one pain point in their workflow,” CoverMyMeds Co-Founder Matt Scantland says. Additionally, doctors spend about eight hours a week dealing with the issue that sometimes leaves patients without necessary medications.

CoverMyMeds Co-Founder Matt Scantland

So what is a prior authorization? “Think of it as a permission slip that your doctor needs to send to your insurance company before they will cover your prescription drug,” Scantland says.

The first time anyone really thinks about the prior authorization process is when it’s too late – when a patient is standing at the pharmacy counter being denied their medication.

“We knew we wanted to work on this prior authorization problem because we had seen that it was this major health issue, and these patients when they don’t get on the drugs that they need are going to end up much sicker,” Scantland says. The process often prompts a patient response of ‘Why won’t they just cover my meds?’ giving rise to the company’s name.

The prior authorization process has traditionally required a trail of paperwork, with each health plan having a slightly different process, creating confusion. CoverMyMeds serves to greatly simply the entire process, taking prior authorization from calls, faxes and paper to a real-time, online process.

“That concept, one place to be able to do the prior authorization process for any drug in any health plan, has been the core value proposition really since we started,” Scantland says.

So how does the process work? A doctor prescribes a medication to a patient. When they go to the pharmacy to pick up their prescription, a claim is sent in real-time to the patient’s insurance company that will then either accept or deny the claim. If the claim is denied, the most common reason is the need for prior authorization.

With CoverMyMeds system, the pharmacist can start the prior authorization right inside of their dispensing system. Before, they would have told a patient to speak with their doctor about the prescription. Now the pharmacist directly shares the prior authorization with the doctor’s office who can then work with their health record system to submit the prior authorization directly to the health plan.

“[Health plans] use our software to automatically approve these prior authorizations without any people looking at it and that can all happen in real-time,” Scantland says.

CoverMyMeds is able to do thousands and thousands of these authorizations an hour, saving massive amounts of time and money by eliminating administrative waste. For comparison, a process that took a few days to a few weeks in calendar time plus 20 to 30 minutes in people time is now a real-time process that takes a few minutes.

The product that is attacking a $10 billion dollar problem in the industry is free for physicians, pharmacists and patients. Health plans and pharmaceutical companies pay to support the service.

Solving a very acute and painful problem, CoverMyMeds counts some of the biggest names in healthcare among their users. They work with pharmacies like Walgreens and Rite Aid, within retail pharmacies at chains like Wal-Mart, Giant Eagle, Costco, Publix and Kmart, as well as mom-and-pop shops. Health plans like Blue Cross Blue Shield, Humana and  Aetna use CoverMyMeds software to process their prior authorizations.

The large market for their services has allowed CoverMyMeds to roughly double in size every year since 2009. Scantland wants to provide his 100 team members with more than they expect out of an employer. Good pay, opportunities to attended conferences and even continue their education, along with extra perks like a chef that cooks lunch every day, landed CoverMyMeds on Inc.’s best places to work list.

Scantland says the product is not an easy one to build, but they have achieved success based on the quality of their employees. With their rapid growth, the company is always looking for new engineers and other specialties to add to their team.

“We want to be the best place for young, ambitious either technical or business people to work in Columbus,” Scantland says.

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