NCPDP Integration Solution Positions Third Party Administrator (TPA) for Exponential Growth

NCPDP standards for electronic healthcare transactions are used in prescribing, dispensing, monitoring, managing and paying for medications and pharmacy services. The National Council for Prescription Drug Programs (NCPDP) standard has made it possible for claims processors, eRx vendors, government agencies (CMS and FDA), health plans, long term care providers, pharmaceutical manufacturers, pharmacies, pharmacists, providers and their trading partners to increase efficiencies as well as easily exchange data.

Likewise, TPAs leverage NCPDP standards for information exchange to process and administer employee healthcare, pharmacy benefits and claims. In order to manage and drive down healthcare costs, employers turn to TPAs to create and administer employee benefits plans. Learn how this leading TPA implemented the PilotFish Integration Solution to automate and standardize processes vital to meeting their client demands and their own aggressive growth targets.

THE CLIENT

The employee benefits plan industry has long relied on highly manual processes to get the bulk of their administrative work done. The company is a leading national TPA that creates and administers benefit plans for employers. They are effecting radical change and leading a transformation in the industry with a new approach that combines new technologies with the experience of the brightest minds in the industry. Their Benefits Administration Services division turned to PilotFish as its partner in building out a digital ecosystem to integrate, track, analyze and report medical, pharmaceutical and member data to automate benefits services, create efficiencies and optimize resources.

THE CHALLENGE

The company was in the midst of a major upgrade of its benefits and claims processing management and systems integration.  The pharmacy benefit process was next up for the elimination of a cumbersome mix of legacy digital and manual workflows bogging down onboarding and integration processes. The complex pharmacy benefit process includes interfacing with PBMSs and retail pharmacy networks as well as integration with internal systems and databases, a claims management system, clearinghouse solutions and member benefit portals. NCPDP SCRIPTS integration was on the critical path and hampered in particular by dependencies on expert developer knowledge in C#. Interfaces were virtually all one-off.

Once started, building an NCPDP interface took several weeks. Competing for developer time, NCPDP interfacing faced backlogs that resulted in delays and rising complaints. Ongoing maintenance and support of NCPDP interfaces was becoming a proverbial nightmare. Another area up for automation was resource-intensive quality checks involving manual inspection steps of claims at various process stages. Staying on pace with exponential customer base growth was a pressing concern that needed to be dealt with.

THE SOLUTION

The company had already turned to PilotFish, Inc., a leader in healthcare integration to address the complexity and issues involved in their healthcare medical and pharmacy benefits data exchange. The Benefits Administration Services’ first priority for PilotFish was to modernize, standardize and automate critical HIPAA X12 EDI integrations. The demonstrated success and measurable quality improvements with that issue added to the impetus to apply PilotFish’s consistent and repeatable integration methodology to NCPDP integration, as well.

PilotFish’s eiConsole for Healthcare supports the full NCPDP SCRIPT specification and data mapping to route and convert NCPDP data to and from any format. With PilotFish’s eiConsole, NCPDP SCRIPT data was parsed, validated and mapped simply and quickly. Interfaces are constructed from a common set of stages via PilotFish’s graphical automated interface assembly line (including Listeners, Processors, Transformations, Routers, and Transports). With drop-down menus, drag & drop mapping and pre-configured screens – building interfaces is easy and fast. PilotFish integrations are self-documenting thus allowing for cost-efficient changes, updates and removing the dependency on scarce developer talent and who created an interface.

PilotFish eiConsole’s NCPDP Format Reader reads in any version of the SCRIPT schemas and builds a representative source or target format. In pharmacy claims processing, a major hurdle is the huge variation in vendor files and formats.  PilotFish’s NCPDP Format Reader, processors and lenient parser are specifically designed to handle that high level of variation effortlessly.  The lenient NCPDP Parser identifies, flags and/or fixes errors, incorrect values, incorrect usages, etc. That functionality automated quality processes that had been highly manual.

PilotFish’s Integration Solution transforms NCPDP data seamlessly while ensuring data quality and reliability. Claims data and accumulator files received daily from PBMS entities were rapidly transformed and routed to internal analytics and reporting functions and updates of medical and pharmacy benefits to member portals. PilotFish easily executed management’s requirements for a portfolio of management reports and Excel spreadsheets now fed by higher-quality data sets.

THE BENEFITS

Simply put, the company is now more effective while saving time and money. Accelerating data flows between internal and partner applications with PilotFish’s Integration Solution streamlined communications and improved business relations with vendors. Leveraging PilotFish, NCPDP pharmacy data exchange processes became standardized and automated – freeing up resources for other projects and eliminating backlogs and delays.

With PilotFish’s integration solution, NCPDP implementations were delivered in a few days, rather than several weeks or longer. PilotFish’s ease of use and intuitive process allows business analysts or other professional staff to do up to 90% of configuration work. The company had already experienced the remarkable operational and quality benefits that accrued with PilotFish solutions applied to critical X12 EDI integrations and was able to leverage the same benefits with NCPDP. Updates and maintenance ahead are projected to require minimal internal resource requirements.

Through the adoption of PilotFish, the company has achieved a single, consistent approach to vendor and pharmacy claims integrations. Regardless of the type of integration, the process is always the same. Staff need only learn one tool regardless of the data formats. This approach allows organizations to highly leverage reuse. Each new implementation can be achieved by cloning an earlier effort and only making minor modifications in the configuration. New client systems can be implemented much more rapidly, which in turn minimizes time invested and costs.

THE FUTURE STATE

PilotFish offers a future proof solution in that it integrates with any database, system or application, and with any data format and communication protocol. Integration and data exchange are easy between NCPDP, EDI, XML, HL7, FHIR and any other source or target. PilotFish’s Integration Solution’s simplicity and sophisticated architecture were critical to the success and speed of the NCPDP implementation. Overall, PilotFish has been a key element of the company’s rapid and ongoing success in overcoming interoperability barriers that were a limiting factor to growth. The company projects that each additional phase of its digital transformation project will be as efficient and cost-effective.

The company is also moving to new clearinghouse solutions for a more responsive and collaborative relationship along with intelligent and agile capabilities to speed up medical and pharmacy claims processes.

The company is adding new functionality enabled by PilotFish in the real-time exchange of healthcare data. Upcoming deployments include a real-time response for eligibility, claims status and authorization information (Eligibility and Benefits: HIPAA X12 270/271 and Claims Status: HIPAA X12 276/277). These real-time capabilities will improve payments and collections, reduce administrative costs and upgrade services to vendors and customers.

PilotFish delivers a complete solution of integrated components that encompass the full lifecycle of integration. With PilotFish, the company can meet its current and new integration requirements with one easy-to-use tool. There is no additional cost to access components or features. These measurable, value-added benefits were part of the impressive Benefits Administration Services success story in meeting the company’s aggressive goals for expansion.

In this period of healthcare transformation and pressures from outside forces, this leading TPA and industry change agent has positioned itself to innovate in meeting pharmacy claims processing and pharmacy benefit management challenges as well as adapt to new technologies and industry changes that evolve or emerge.

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X12, chartered by the American National Standards Institute for more than 35 years, develops and maintains EDI standards and XML schemas.