Introduction
Compounding pharmacies play a vital role in the pharmaceutical industry by customizing medications for patients with unique needs. Customization may be necessary when no commercially available medication meets a patient’s requirements, when a patient cannot take standard pill forms, or when allergies to certain ingredients in mass-produced drugs make off-the-shelf options unsuitable.
However, compounding fraud1 is a growing concern, with some operators manipulating drug compositions by adding unnecessary ingredients to inflate prices. Fraud prevention solutions help combat such practices by analyzing medication ingredients and identifying only those that are eligible for reimbursement.
One of our customers, an independent compounding management company, developed a fraud prevention solution leveraging their deep expertise in permissible compounds and dosage quantities. This knowledge was embedded as business rules within the system, enabling automatic validation and ensuring fair and transparent pricing.
Now, the customer faced an unexpected situation, because of which they were left with two choices – rebuild the solution from scratch in 90 days or pay double the licensing fees to continue using the solution.
This is when HealthAsyst stepped in and helped them rebuild, optimize, and automate the entire system within the tight deadline.
Beyond Business Continuity Risks
Beyond the urgency of the immediate situation and risks to business continuity, the new solution had to integrate with Clearinghouses and Pharmacy Benefit Managers (PBMs) to enable real-time pharmacy claims processing in under 3 seconds.
The new system also needed to be built while minimizing development costs and ensuring business continuity. It had to automate ingredient-level pricing to handle frequent price changes efficiently. Furthermore, the system had to adopt a standardized format for smooth pharmacy-payer communication. It also had to improve data storage & monitoring by eliminating the reliance on flat files.
Development Agility & Automation for Scale
HealthAsyst prioritized must-have features to be built for a Minimum Viable Product (MVP) within the first month. We implemented the National Council for Prescription Drug Programs’ (NCPDP’s) standardized electronic communication format. This helped facilitate smooth claims processing between pharmacies, Clearinghouses and PBMs. Further, we designed a robust rules engine for automated validation of medication ingredients to ensure pricing accuracy.
Next, we migrated data from flat file formats to a relational database. Doing this helped achieve better performance. For cloud-readiness, we used docker containers early in development.
For quality assurance, we utilized a combination of our proprietary test automation framework, and an open-source tool. As a result, regression testing for the system could be done in just 1 hour, freeing up the team to spend time and effort on new feature development.
To control costs, we avoided expensive commercial software, instead using open-source technologies.
Cost Savings, Faster Processing & Immediate ROI
Using the approach, we achieved the following results for our customer:
- Complete Solution Rebuilt in 90 Days: The MVP was ready in just 30 days, allowing for rapid iteration and full implementation within the 3-month deadline.
- Immediate ROI Realization: The customer avoided paying the vendor’s hefty licensing fees and realized ROI within the first month.
- Accelerated Claims Processing: The system maintained its 3-second processing benchmark, ensuring zero business disruption.
- Improved Scalability & Maintainability: Docker containerization enabled easy scalability, updates, and minimal downtime.
- Efficiency Gains from Automation: 1,500 automated test cases reduced manual QA effort, and full regression testing was completed in just 1 hour instead of days.
Conclusion
By partnering with us, the customer wasn’t just able to rebuild a fraud prevention solution within 90 days, but they were also able to further optimize it, improve its scalability and automated QA efforts. The new solution ensures quick real-time claims adjudication, automated pricing validation and smooth integration with the PBM.
To discuss your product engineering needs, please write to us at itservices@healthasyst.com.
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References:
1 https://www.rivkinradler.com/publications/compounding-the-fraud-questionable-billing-by-pharmacies/
