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/.

The following article, “ Medication Therapy Management : Benefits and Cost Savings ” talks to the potential benefits and importance of implementing a Medication Therapy Management, or MTM program to provide better patient care. With the growing concern and downfalls of medication mismanagement, having MTM programs in place is essential to address the problem.

“Problems related to medications and the mismanagement of medications is estimated to lead to 1.5 million preventable adverse events each year, resulting in $177 billion in injury and death according to the American Pharmacists Association (APhA).”

Health Plans are now adopting these services as a way to offer their members a higher level of care, however, they are increasingly pressured to adhere to growing requirements while sustaining, if not reducing, their existing workflow. With Agadia’s Medication Therapy Management solution, RxMTM+, Health Plans can overcome these challenges to drastically improve productivity, process automation, and overall quality of care.

RxMTM+ is a fully customizable platform leveraged to automate a Health Plan’s MTM process and is positioned to address evolving CMS guidelines enabling Health Plans to ensure proper patient therapy, save valuable time and money, and meet CMS requirements.

Interested in learning more? Contact us today to schedule a live demo.

Click here to read the full article.

Prior Authorization

The following article, “Prior Authorization Call Shows Inefficiency, Absurdity of Process” represents a tiresome challenge confronting the Healthcare industry, while also representing the foundation behind Agadia’s core mission, to improve quality of care and expedite the delivery of critical health care services by advancing and automating Utilization Management processes.

This article, in particular, talks to the mundane process of completing a Prior Authorization, arguing that “PA phone calls rank high among physicians’ top burdensome issues, with one study estimating that physicians spend more than 868 million hours each year in PA-related activities.”

At Agadia, while our PA solution, PAHub™, is designed for use by Health Plans and Pharmacy Benefit Managers (PBMs), its end-to-end management of the prior authorization process will result in efficiencies for all parties involved.

PAHub is a web-based solution uniquely designed to automate the management of Electronic Prior Authorization (ePA) across all healthcare services, all lines of business, and all channels. With PAHub, Health Plans and PBMs have the tools at their 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.

Real-time integration with the nation’s leading enterprise systems, EMR vendors and physician portals is paying dividends to many of Agadia’s clients in streamlining the prior authorization process.

Interested in learning more? Contact us today to schedule a live demo.

Click here to read the full article.

Parsippany, NJ and Milwaukee, WI – August 9, 2016 – Agadia Systems, Inc. (Agadia), known for its innovative utilization management solutions used by the nation’s leading Health Plans and PBMs, and Serve You Custom Rx Management (Serve You), an independent, full-service pharmacy benefit manager (PBM), announced the signing of an agreement, effective August 1, 2016, for Serve You to utilize Agadia’s Electronic Prior Authorization solution, PAHub, for optimization of Serve You’s prior authorization process.

Agadia’s web-based solution, PAHub™, is uniquely designed to automate the end-to-end management of prior authorization across all healthcare services, all lines of business, and all channels, enabling health plans and PBMs to facilitate electronic prior authorization, reduce costs and increase productivity. By providing full control over all clinical, compliance and administrative aspects of prior authorization management, PAHub strongly aligns with Serve You’s continuous effort to provide on-going enhancements that are both cost-effective and clinically appropriate for its members.

“As with all clients in our portfolio, we are fully committed to providing the utmost quality in our innovative thinking and customer support. We take great pride in driving operational and clinical efficiencies for our clients and look forward to observing Serve You’s amplified success from a streamlined prior authorization process.” says Scott L. Furletti, Vice President, Business Development 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 Serve You:
Serve You Custom Rx Management has been the pharmacy benefit manager (PBM) of choice for benefit and insurance brokers and consultants and their clients, including employers, unions, coalitions, and governmental entities, as well as third party administrations (TPAs) who are looking for a valuable partner to effectively manage prescription drug costs.
Privately held since inception in 1987, Serve You remains an independent, full-service PBM that has built and expanded its capabilities from the ground up by choosing to invest in hardworking people, systems and processes, rather than outsourcing key PBM functions.

Click here to read the full press release

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