How RelayHealth integration makes medical claim processing easy for pharmacies

After Amazon’s retail and Uber’s taxi revolution, we’re now witnessing a pharmacy revolution.

A decade ago, the pharmacy retail market was in a nascent stage with stand-alone pharmacies adopting digital models of doing business. But today the retail pharmacy industry is expanding its wings towards on-demand drug deliveries and streamlined insurance approval process.

At Quovantis, we work with one such client. Our partners (we refer to our clients as partners) are an on-demand e-pharmacy leveraging technology to run same-day prescription delivery services.

For the consumer the process is fairly simple. You visit a Doctor. The Doctor shares a diagnosis and prescribes you medicines. You go home, log into the mobile app, enter your digital prescription, and select a delivery time. The app receives it instantly, assembles the prescription, and a driver picks up the medicines from the pharmacy to deliver it at your doorstep.

Easy as a breeze right?

For the consumer, absolutely.

But it’s a herculean task of epic proportions behind the scenes.

This article is for those who want to deep dive into ‘what goes behind the pharmacy management systems’.

Short answer– prescription verification, integration with insurance providers, automation of drug inventory, prescription fulfillment, optimizing delivery routes, and then tracking the deliveries. Oh my!

Long answer– Take a seat, because this is going to take a while.

From a retail standpoint, a typical pharmacy in the U.S. interacts with the below players.

• Consumers
• Insurance providers
• Doctors/Hospitals
• Drug manufacturers/wholesalers

They interact with each other in an organized yet chaotic manner.

When a consumer goes to a pharmacy with a prescription, the pharmacist has the job of verifying consumer’s insurance, getting approvals, running authorization of prescribed medication, contacting the patient for pay/copay options. With technology, all this clearance that earlier took days, happens within hours. Through multiple API integrations running in the background, it’s much faster to retrieve information related to patient’s insurance, and payment details.

The services that help run these API integrations as a bundled solution are called healthcare connectivity services (HCS). HCS play an important role in managing the clinical, financial, and administrative interaction between all the above players– patients, providers, payers, pharmacies, and manufacturers. With our partners, we have first-hand experience of the many advantages of using healthcare connectivity services. So, if you’re someone who’s looking to build your own e-pharmacy platform, keep reading.

This article shares our experience of integrating the RelayHealth pharmacy solutions APIs. Before I jump into more details, let me first share why we chose RelayHealth pharmacy solutions for medical claim processing.

Our partner was already using the Mckesson PBM program for services required in their day to day activities. In the Mckesson PBM program, RelayHealth is already bundled to provide the medical claim processing services. Moreover, RelayHealth is a widely used solution in terms of claim processing– it processes 18 billion pharmacy transactions annually. With its popularity, we could trust it with optimum support of our strategic needs. Moreover, it has a secure and robust SaaS-based infrastructure.

As we started using it, we realized it’s many advantages. I’ve listed a few of them below–

Easy to follow documentation

In the US, the National Council for Prescription Drug Programs (NCPDP) is an organization responsible for maintaining standard formats for the e-submission of third party drug claims and its related transactions. After NCPDP released guide D.0, RelayHealth used this standard to build a standard communication platform for all healthcare businesses.

RelayHealth provides a “self-supported” document to connect to their eClaims service. In this document, they have mentioned details like–

• The security protocol used for the communication with the RelayHealth
• Messages formats and header requirements along with the examples

Option to test all use cases

To test your implementation, especially the exchange of messages (request/response), RelayHealth provides the test environment where you can log in and test your request and response part.

They also provide a complete set of test cases to check all scenarios. For this, they provide the fictitious NPI ID (unique identifier of the pharmacies) which is sent in the header of the messages sent to RelayHealth to confirm the authenticity of the pharmacy. Once the application is production-ready, this fictitious NPI ID is replaced with the original NPI ID.

Follows the necessary security guidelines

All eClaims transmission through RelayHealth meet The Health Care Finance Administration (HCFA) regulations regarding the transmission of patient-specific healthcare information via the internet.

RelayHealth uses RFC 5246 TLS Protocol standard to transmit the proprietary message.

Each transaction message is encrypted in byte form with mandatory identifying header and other message wrapper fields that form a complete message packet.

It uses SSLSocket to construct an SSL connection from the client-side to the RelayHealth’s given address and port. This adds a added layer of security protections over the underlying network transport protocol.

How we used RelayHealth integration for faster claims processing?

Here’s a sample narrative of what happens when we receive a prescription–

When a customer comes or sends his/her prescription to the pharmacy, we check if the customer is new or an existing one. If he/she is an existing customer, we fetch all the medical insurance details from our database and start processing.

If the customer is new, we create a fresh account in our database and hit the RelayHealth API to get all the insurance details of that person. It returns the list of the insurance providers that the customer has subscribed to.

To further process the medical claim on the prescription provided by the customer, we run the processing with any one of the insurance providers in the list through RelayHealth. RelayHealth further sends the request to the concerned insurance provider to process it. In response, we get the details about the co-pay that the customer has to pay.

In some cases where customers have more than one insurance provider, they wish that the remaining co-pay amount to be paid by other insurance providers from the list. In such cases, we again run the same process with this second insurance provider through RelayHealth and share all the details that the previous insurance provider sent to us regarding the claim. Once we get the response from the second insurance provider, we inform the customer about how much their second insurance provider is ready to pay or how much co-pay amount they have to pay.

We have also built one of the features called pre-benefit determination. Doctors can consult the pharmacies to check how much the patient would have to copay if they prescribe a particular branded medicine. If the patient says no (depending on the copay amount) then the doctors prescribe a substitute– generic medicines that are less costly. With RelayHealth integration we leverage this feature to doctors and patients to know the co-pay amount in advance.

Once the claim processing clears out, we proceed with the other processes to make the prescription ready for the delivery.

RelayHealth integration has helped us reduce payment obstacles, save time and effort and boost pharmacist’s productivity to a great extent. With improved productivity, the pharmacy can focus on tasks such as scaling their operations, providing a better user experience and optimizing patient interactions.

Note- This is not a sponsored post. Everything I shared is from my own experience, and we don’t have any affiliate agreement with RelayHealth. Also, this by no means should be considered a promotion post for RelayHealth, this only shares our journey in using their platform.

I wrote this blog for our Medium Publication- Unboxing Product Management. The publication is a weekly column by people of Quovantis to share their learning.