CAQH CORE

As validated in the following article, the healthcare industry’s approach to prior authorization is evolving. In parallel, such rapid change results in the need for advanced technology to streamline workflows. Agadia, an innovator in healthcare technology, is addressing these needs for the nation’s leading health plans and PBMs with PAHub, a web-based solution uniquely designed to automate the end-to-end management of Electronic Prior Authorization (ePA) across all healthcare services, all lines of business, and all channels.

Processing thousands of ePAs daily, Agadia’s PAHub solution is changing the landscape of prior authorizations and driving better patient outcomes as the end goal. Contact us today to request a live demo and explore how PAHub can bring operational and clinical efficiencies to your prior authorization management.


The following article was originally posted on HealthPayerIntelligence.com on July 27th, 2018 by Thomas Beaton.

CAQH CORE supports and urges industry-wide collaboration on how to improve prior authorizations to be more beneficial for patients, payers, and providers.

CAQH CORE is urging healthcare payers, providers, and other stakeholders to promote industry-wide collaboration on how to improve prior authorizations.

Leading provider and payer organizations, including AHIP, AHA, the BlueCross BlueShield Association, and MGMA, have already signed an agreement to reduce complexity and standardize the processes of prior authorization.

“We are greatly appreciative of the consensus statement authors’ commitment to this critical issue,” said Robin J. Thomashauer, President of CAQH. “CAQH CORE participating organizations have spent considerable time developing ways to promote greater automation in the prior authorization process. We agree wholeheartedly with the consensus statement, and are eager to work together to make a difference.”

CAQH CORE and the signatories of the consensus letter aim to improve prior authorizations with two-way communications and transparency, so all stakeholders can easily process prior authorization requests.

In addition, both CAQH CORE and the signatories want to add features to prior authorizations that address continuity of care concerns and leverage electronic prior authorizations to enhance efficiency.

Prior authorizations help payers contain care costs for expensive medications and services, but can also contribute to delays in care and add patient safety risks. Payers that utilize electronic and streamlined prior authorization processes could help reduce patient delays in care and experience significant savings

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Electronic Prior Authorization BillLast Tuesday, the House of Representatives unanimously passed legislation requiring healthcare professionals to submit prior authorization requests electronically for drugs covered under Medicare Part D.

“This change highlights the importance of maintaining a clinically and operationally efficient electronic prior authorization management process. Not only is it now essential that your business follow the latest requirements as outlined in this article, it will be equally as important that your business can adapt to these changes in an effectual manner that allows for reduced turn-around times and increased productivity.” – Ross Loomis, VP of Sales, Agadia.

Agadia’s leading solution, PAHub, is uniquely designed to automate the end-to-end management of Electronic Prior Authorization (ePA), enabling Health Plans and PBMs to adhere to the latest regulations and control all clinical, compliance and administrative aspects of ePA directly at the point-of-care.

In addition to working with some of the nation’s leading Health Plans and PBMs with respect to their Prior Authorization management, Agadia’s suite of solutions can be used to address legislation’s latest provisions tackling the opioid epidemic, such as the Part D prescription drug plan and newly expanded medication therapy management requirements under the PASS Act.

RxSentinel+, Agadia’s Part D Star Ratings and Medication Adherence software, offers the ability to identify, communicate and counsel non-adherent patients, providing a distinct head start in improving patient adherence to medications.

RxMTM+ is Agadia’s fully-customizable Medication Therapy Management (MTM) solution, positioned to ensure proper patient therapy, save valuable time and money, meet CMS requirements for CMRs & TMRs, and prepare for audits with accessible reporting archives.

Contact us today to schedule a demo and explore how our cutting-edge technology can significantly enhance your approach to utilization management.

PARSIPPANY, N.J. and Amarillo, TX – June 25,2018 – Agadia Systems, Inc. (Agadia), an innovator in electronic prior authorization and MTM solutions, and MaxorPlus, a full service PBM pioneering the use of mobile technology to improve clinical outcomes, have announced the signing of an agreement for MaxorPlus to leverage PAHub, Agadia’s leading Electronic Prior Authorization solution, for optimization of MaxorPlus’s prior authorization process.

Agadia’s web-based solution, PAHub™, automates the end-to-end management of prior authorization across all healthcare services, all lines of business, and all channels. With the use of PAHub, Maxor will maintain control over all clinical, compliance and administrative aspects of their prior authorization management.

“In today’s healthcare environment, every successful operation must find ways to leverage technology to increase capabilities and improve efficiencies,” said Mike Einodshofer, Chief Innovation Officer, Maxor. “PAHub not only allows us to expedite our internal clinical review, it also allows us to connect to prescribers in ways that improve communication flow and simplify the authorization process. This allows us to get medications to patients as expeditiously as possible, while ensuring clinical appropriateness and cost effectiveness. “

“We look forward to playing a significant role in Maxor’s continued success in driving clinical and operational efficiency. Our commitment to quality, innovation and our customer relationships differentiates us in the market place. PAHub is enabling the nation’s leading health plans and PBMs to facilitate electronic prior authorization, reduce costs and maintain full control of their utilization management programs.” says Ross Loomis, Vice President, Sales of Agadia.

About Agadia: Agadia is a leading healthcare technology company addressing the evolving needs of the managed care market with a suite of utilization management solutions in electronic prior authorization, MTM, Part D star ratings and adherence, and formulary benefit design. Used by the nation’s largest health plans and PBMs, Agadia’s advanced technology solutions help drive operational efficiency, appropriate utilization, compliance, and profitability.  For more information, visit www.agadia.com.

About Maxor:

Maxor is a market-leading Pharmacy Benefit Manager that delivers service excellence with innovative capabilities in clinical management, analytics, and member engagement to help clients lower pharmacy costs while improving health outcomes. Maxor’s PBM platform is complemented by Maxor Pharmacy Management & Consulting Services, a provider of outpatient pharmacy management solutions, and Maxor Specialty, a clinically-driven specialty pharmacy focused on rare and orphan diseases. These capabilities allow Maxor to offer customized solutions to diverse market segments including hospitals and health centers, employers, labor groups, and public entities. For more information, visit www.maxor.com .

Click here to see the full press release. 

prior authorizations

As noted in the following article posted on AMJC.com by Kelly Davio, prior authorizations are having a significant negative impact on clinical outcomes and causing a delay in care. This challenge is the driving force behind Agadia’s prior authorization solution, PAHub, which is used by some of the nation’s leading Health Plans and PBMs to streamline the prior authorization process and ultimately create better patient outcomes.

PAHub™ is a web-based solution uniquely designed to automate the end-to-end management of Electronic Prior Authorization (ePA) across all healthcare services, all lines of business, and all channels. With PAHub, you have the tools at your fingertips to control all clinical, compliance and administrative aspects of Prior Authorization at the point-of-care to reduce turn-around times and increase operational and clinical efficiencies.

In a recent case study involving a health plan specializing in State Medicaid business, Agadia’s solution, PAHub, enabled the health plan to increase their prior authorization processing speed by 133%, among several other benefits. Health Plans and PBMs can and should leverage technology like PAHub to overcome the growing challenges outlined below. Contact us today to learn how PAHub can automate your prior authorization process.

AMA Survey: Prior Authorizations Delay Access, Negatively Impact Clinical Outcomes

Kelly Davio

Prior authorizations (PAs) delay care, have a significant negative impact on clinical outcomes, and place a high burden on providers, according to a survey of physicians conducted by the American Medical Association (AMA).

In 2017, the survey investigated attitudes toward PAs among 1000 practicing US physicians (40% primary care physicians and 60% specialists) who provide 20 hours or more of patient care per week, and who complete PAs as part of a typical week in practice. The 27 questions assessed wait times, outcomes, and burden of completing PAs.

Most physicians (64%) reported waiting at least 1 business day after submitting a PA for a decision from a health plan, and 30% reported waiting at least 3 business days. Nearly all (92%) physicians said that PAs delay patients’ access to necessary care, with 38% of respondents reporting that PAs “sometimes” create delays, and 39% saying that they “often” delay care.

The importance of Medication Adherence in today’s marketplace has grown significantly. The following article substantiates the need to address the challenges around patient safety and appropriate medication use.

At Agadia, we are working to help the nation’s leading health plans and PBMs to seamlessly and effectively create better patient outcomes. Our Medication Adherence solution, RxSentinel+, allows Health Plans and PBMs to customize programs leading to higher levels of adherence and improved CMS Star Ratings.

RxSentinel+ makes it easier to track, monitor and report on the CMS star rating measures. RxSentinel+ enables health plans and benefit managers to design and manage patient safety and medication adherence programs to achieve higher Clinical and Formulary medication compliance.



The following article was originally posted by Charles Lee, MD, senior director, Clinical Knowledge – Meducation, First Databank (FDB) | February 13, 2018 on www.beckershospitalreview.com

Patient understanding – The cornerstone of patient adherence and safety

What percent of patients walk out of a pharmacy not knowing how to use their medicine correctly?

According to the Institute of Medicine, chances are that one in every three patients will have some difficulty understanding their medication instructions. [IOM, 2004] These patients have low health literacy. With 4.45 billion prescriptions dispensed in the United States last year, over 1.5 billion prescriptions pose a potential safety risk if the patient doesn’t take their medicine properly.

Opioid Overutilization

The Pharmacy Quality Alliance (PQA) recently released a press release titled, PQA Receives NQF Endorsement of Three Performance Measures to Address Opioid Misuse/Abuse. This press release emphasizes the drastic increase in overdose mortality from 2014 to 2015 and the growing need for measures to help Health Plans battle the epidemic of prescription opioid abuse.

Agadia is proud to offer an innovative solution to address this epidemic. RxSentinel+ provides a fully customizable platform to track, monitor and report on opioid over-utilization and utilization of high-risk medications, allowing Health Plans to tailor programs for better patient outcomes and higher levels of adherence, while also complying with growing CMS guidelines. The ability to identify, communicate and counsel patients provides a distinct head start in improving appropriate utilization and patient adherence to medications. RxSentinel+ takes the next step in adherence management by letting the Health Plan define all requirements for identification and intervention with user-friendly set-up functionalities.

With RxSentinel+, Agadia is providing all of the tools at the Health Plans’ fingertips to fight the opioid epidemic head-on. Contact us today to schedule a live demo and learn how you can benefit from using RxSentinel+.

Click here to read the press release from PQA.

Wolters Kluwer published an insightful podcast regarding how morphine equivalent dosing standards and new decision support technology can help professionals screen, spot and prevent opioid overutilization.

Health Plans and PBMs are starting to leverage Agadia’s Star Ratings and Medication Adherence solution, RxSentinel+, to address the opioid epidemic. RxSentinel+ provides a fully customizable platform to track, monitor and report on opioid over-utilization and utilization of high-risk medications, allowing Health Plans to tailor programs for better patient outcomes and higher levels of adherence, while also complying with CMS guidelines. The ability to identify, communicate and counsel patients provides a distinct head start in improving appropriate utilization and patient adherence to medications. RxSentinel+ takes the next step in adherence management by letting the Health Plan define all requirements for identification and intervention with user-friendly set-up functionalities.

Contact us today to schedule a live demo of RxSentinel+ and learn how you can gain fight the opioid epidemic.

Click here to listen to Wolters Kluwer’s podcast.

Medication Adherence

Agadia Systems, Inc. (Agadia), a recognized innovator in healthcare technology solutions for utilization management, is helping Health Plans and PBMs to address non-adherence to prescription drugs through RxSentinel+. RxSentinel+ is a Part D Star Ratings and Adherence solution that enables Health Plans and PBMs to design and manage patient safety and medication adherence programs to achieve higher clinical and formulary medication compliance.

As quoted in the New York Times recent article, Nonadherence To Prescribed Medications Is An “Epidemic” In The US, by Jane E. Brody, “This lack of adherence, the Annals authors wrote, is estimated to cause approximately 125,000 deaths and at least 10 percent of hospitalizations, and to cost the American health care system between $100 billion and $289 billion a year.”

With RxSentinel+, Agadia is enabling Health Plans and PBMs to identify, communicate and counsel non-adherent patients, leading to better patient outcomes, higher levels of adherence, and improved CMS star ratings. Contact us today to schedule a live demo and learn about the many benefits of using RxSentinel+.

About Agadia:
Agadia is a leading healthcare technology company addressing the evolving needs of the managed care market with a suite of utilization management solutions in electronic prior authorization, MTM, part d star ratings and adherence, and formulary benefit design. Used by the nation’s largest health plans and PBMs, Agadia’s advanced technology solutions help drive operational efficiency, appropriate utilization, compliance, and profitability.

HITRUST Certification validates Agadia is committed to meeting key healthcare regulations and protecting sensitive private healthcare information

PARSIPPANY, N.J., April 12, 2017 /PRNewswire/ — Agadia Systems, Inc. (Agadia), a leader in utilization management solutions leveraged by the nation’s largest Health Plans and PBMs, today announced that Agadia has earned Certified status for information security by the Health Information Trust (HITRUST) Alliance. With the HITRUST CSF Certified Status, Agadia’s Prior Authorization solution, PAHub, meets key healthcare regulations and requirements for protecting and securing sensitive private healthcare information.

HITRUST CSF Certified status indicates that PAHub has met industry-defined requirements and is appropriately managing risk, and places Agadia in an elite group of organizations worldwide that have earned this certification. By including federal and state regulations, standards and frameworks, and incorporating a risk-based approach, the HITRUST CSF helps organizations address these challenges through a comprehensive and flexible framework of prescriptive and scalable security controls.

“Health Plans and PBMs are under great pressure to meet complex compliance requirements that include technical and process elements such as HIPAA, NIST, ISO and COBIT. At Agadia, our historic ability to adhere to these guidelines is a source of great pride for us. This certification further validates our efforts and demonstrates our commitment to meet the gold-standard in safeguarding PHI.” – Scot Lovejoy, Chief Pharmacy Office & Chief Privacy Officer, Agadia.

“HITRUST has been working with the industry to ensure the appropriate information protection requirements are met when sensitive health information is accessed or stored in a cloud environment. By taking the steps necessary to obtain HITRUST CSF Certified status, Agadia is distinguished as an organization that people can count on to keep their information safe.” – Ken Vander Wal, Chief Compliance Officer, HITRUST.

About Agadia
Agadia is a leading healthcare technology company addressing the evolving needs of the managed care market with a suite of utilization management solutions in electronic prior authorization, MTM, part d star ratings and adherence, and formulary benefit design. Used by the nation’s largest health plans and PBMs, Agadia’s advanced technology solutions help drive operational efficiency, appropriate utilization, compliance, and profitability. For more information, visit www.agadia.com.

Click here to read the full press release.

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For over 10 years, Agadia has been committed to improving the quality of care and the delivery of health care services. This holiday season, we are gearing our efforts towards delivering joy to local children in need by becoming a 2016 National Corporate Donor of Toys for Tots.

Toys for Tots is a top-rated charity that provides toys, books and other gifts to less fortunate children. Learn how you can contribute by visiting http://www.toysfortots.org/.

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