iProjects Solutions for Clinical Services mainly covers the following areas

Service Overview

Utilization Management (UM)

Our team of physicians and pharmacists conducts Utilization Management program that includes Prior Authorization, Step Therapy and Appeals. We review the request, based upon established proprietary guidelines, clinical protocols for proper medication use, current medical literature and standards of care, along with member-specific information, in order to establish the validity of the request and whether the current therapeutic situation conforms to clinical guidelines. We provide standard and expedited reviews, according to the guidelines established by CMS.

Medication Therapy Management (MTM) and Therapeutic Interchange (TI)

Our proprietary software conducts automated screening of claims against established clinical guidelines and algorithms and flags Drug-Drug Interaction, Drug-Disease interaction, Drug Adverse effects, Drug Duplications etc. for intervention to improve overall quality of care. Our MTM program enhances beneficiary understanding through education and interventions by carrying out extensive health risk assessments and communicates the findings to providers and the members as per CMS’ guidelines.

Our Therapeutic Interchange program identifies high-cost prescriptions or branded drugs and recommends bio-equivalent cost effective generic in the Plan formulary. This program, runs in conjunction with Medication Therapy Management or stand-alone.

Formulary management

iProjects sponsored Service Providers have Physicians and Pharmacists who develop, update and maintain the formulary. Periodically, we review all new medications, indications for medications and every drug class, and based upon strength of scientific evidence and standards of practice, we recommend changes in formulary. The system includes the methods which the organization uses to evaluate and select the medications for different diseases, conditions, and patients. After the release of Formulary reference file, formulary is updated by making the changes like: Addition, Deletion, and Tier Change.

Pharmacy Help desk

iProjects Pharmacy Help Desk includes specially trained individuals that consistently meet or exceed industry standards for answering and resolving incoming inquiries. The Call Center staff serves pharmacies, plan participants, physicians and plan administrators on Claim adjudication, pharmacy contracting, Claims processing support, MTM- patient interview and clinical data collection, Prior Authorization (PA) support, Emergency coverage overrides etc.

Claims Review and Claims Analytics

The claims analytic function primarily deals with prescription claims data and focuses on utilizing members, Provider, Pharmacy, protected class etc. Our analysis also focuses on detecting questionable, fraudulent or abusive billing practices and provides data for further investigation and follow up action.

Coverage Management & Appeals

A coverage determination is a decision by a Medicare drug plan about whether or not to cover a prescribed medication under the Part D program. In most cases, drug plans determine that prescribed medications are medically necessary and approve coverage. But a plan may decide not to cover a drug for several reasons such as:

• The drug is not on the plan’s formulary.
• The plan determines the drug to be not medically necessary.
• The plan restricts coverage to a specific dosage of the drug.
• The drug is subject to prior authorization, step therapy, or another utilization management restriction.
• The drug is covered under Medicare Part A or Part B.
• An out-of-network pharmacy furnishes the drug.
• The plan sponsor determines that the drug is excluded from Part D coverage.

When a coverage determination is unfavorable, or “adverse,” the enrollee may appeal against the drug plan’s decision. There are five steps in the appeals process. In each step, beneficiaries must make their request for further action within 60 days of receiving notice of the prior, unfavorable response.

iProjects sponsored Service Providers have has in house physician supervised pharmacists to facilitate Prior Authorization (PA) programs. Our Prior Authorization Program reduces the standard procedure turnover time from 72 hours mandated by CMS to 48 hours. We also provide an expedited procedure where authorization can be procured within 24 hours. iProjects provides a dedicated Clinical Services team to handle Clients’ account and is equipped with specialized Clinical Customer Support Help Desk working 24x7x365 hrs. to help registering.

MTM & Therapeutic Interchange

MTM Program

Medication Therapy Management System (MTMS) is intended at optimizing therapeutic outcomes thus promoting safe and effective use of medications which can lead to overall reduction in health care expenditure both for the beneficiary as well as the PDP.

Our MTM program is fully compliant with CMS Guidelines. The MTM Program has been designed keeping in mind the MTM 2011 guidelines mandated by CMS. The program satisfies all the requirements besides incorporating additional features for better assessment of patient conditions.

• Flexible of Eligibility Parameter Setting: The parameters need to be selected at the start of the program to detect the eligible beneficiaries. This parameter selection is fully flexible within the boundaries drawn by CMS as all the chronic diseases are included – clients may select any core and non-core chronic disease.
• Patient-Centered Approach: The program ensures that each patient is on the correct dosing regimen for each medication. Moreover drug safety measures are suggested considering each patient’s medical conditions and current medication compliance data derived by applying standard algorithms for MPR. Patient and providers are considered for follow up interventions where appropriate.
• Automated Drug Conflict Identification: The program employs iProjects proprietary software for identifying potential drug conflicts for MTM eligible patients so that no possible incompatibilities between medications are overlooked.
• Health Outcomes Assessment: The iProjects MTM program incorporates Evidence Based Medicine guidelines to generate tailor made recommendations for each eligible beneficiary. Health Outcomes are measured by HEDIS guidelines.

Our MTM program provides the following key services

• A Comprehensive Medication Review via telephonic interview is done at least once during the calendar year. The consultation is provided by trained and qualified MTM professionals.
• Quarterly Targeted Reviews are done at least once for each quarter for each patient where the identified drug conflicts are processed and the concerned prescribers are informed through secure fax.
• Coordination with Prescribers for better assessment of patients’ conditions and suggesting effective recommendations to resolve the medication conflicts.
• Follow Up consultations are provided to patients where new issues arise during the course of the monitoring in the subsequent reviews.
• Drug Conflicts targeted are as follows: Drug-Drug Interactions, Therapeutic Duplications, Beers’ Alerts, Drug-Disease Interactions, Drug-Allergy Interactions.
• Educational Materials are provided to the patients so that they can better understand their medical conditions and manage the complications better.
• Health Outcomes are measured by comparing the results of interventions with the HEDIS 2010 criteria.
• CMS Reporting as per guidelines

Therapeutic Interchange (TI)

The act of advising a therapeutic alternative, (defined as Medicinal products containing different or same active ingredients but which are of the same pharmacological class, and which have similar therapeutic effects and adverse reaction profiles when administered to patients in therapeutically equivalent doses above, in accordance with a protocol previously established and agreed between Payer and Prescriber). Therapeutic interchange may be within or outside a formulary system.

Firstly we identify the targeted drugs for which we recommend substitute drugs.

• Generic alternatives: Medicinal products, intended for administration by the same route and the same dosage form, containing the same amount of the same active ingredients and meeting the required regulatory and pharmacopoeia standards, the same satisfactory standards of quality, safety and efficacy and are bioequivalent.
• Therapeutic alternatives: Medicinal products containing different active ingredients but which are of the same pharmacological class, and which have similar therapeutic effects and adverse reaction profiles when administered to patients in therapeutically equivalent doses.

Formulary Management

Our team, consisting of physicians and pharmacists who develop, update and maintain the formulary. Periodically, we review all new medications, indications for medications and every drug class, and based upon strength of scientific evidence and standards of practice, we recommend changes in formulary. We play a key role in defining and establishing policies on the usage of drug products and therapies, identifying therapies that are medically appropriate and cost effective.

Formulary management is an integrated patient care process which enables physicians, pharmacists and other healthcare professionals to work together to promote clinically sound, cost-effective pharmaceutical care.

A drug formulary is a continually updated list of medications which represent the current clinical judgment of physicians and other experts in the diagnosis and treatment of disease and preservation of health.

A formulary system is much more than a list of medications that are approved for use by a managed health care organization. The system includes the methods which the organization uses to evaluate and select the medications for different diseases, conditions, and patients. Policies and procedures for the procuring, dispensing, and administering of the medications are also included in the system.

Our formulary management team performs the following key tasks:

• Identify the Positive Formulary Changes
• Changing from higher tier to lower Tier
• Check the NDC number
• Including lower strength of medication when higher strength is already present
• Include generic version when patent is expired for brand
• Include medication having same or lower cost than formulary medications based on PA request
• Reviewing all drugs included in each therapeutic class
• Review of all Step Therapy, Quantity Limit, and Prior Authorization protocols
• Review of any new forms developed to assist in implementing Step Therapy, Quantity Limit, Prior Authorization or Formulary Exception processes
• Discuss with the P&T committee about the changes and get approval
• Formulary Brands vs. Generic analysis and utilization are done every month
• Pharmacoeconomic Analysis is done every month

Pharmacy Help Desk

Our Pharmacy Help Desk includes specially trained individuals that consistently meet or exceed industry standards for answering and resolving incoming inquiries. These representatives are continually monitored to assess accuracy and professionalism. The Call Center staff serves pharmacies, plan participants, physicians and plan administrators.

Help Desk representatives will assist network pharmacies nationwide with specific claim information.

Through our pharmacy help desk we provide pharmacy as well member support. Pharmacy support includes Claims Adjudication, Pharmacy contracting and Marketing & Promotion. Member support includes Claims processing support, MTM- patient interview and clinical data collection, Prior Authorization support, Emergency coverage overrides, Coverage related queries and Providing Benefit plan details.

Claims Analytics

The claims analytic function primarily deals with prescription claims data and focuses on utilizing members, Provider, Pharmacy, protected class etc. Our analysis also focuses on detecting questionable, fraudulent or abusive billing practices and provides data for further investigation and follow up action.

By use of our claims data warehouse and analytic tools, we analyze paid claims as well as rejected claims data and provide various reports.

Paid claims analysis focuses on the following factors

Rejected claims analysis focuses on the following factors: