Friday, September 16, 2022

The Pulse of Electronic Benefit Verification Solutions: Know the Facts

Today’s guest post comes from Edward Hensley, Chief Commercial Officer at AssistRx.

Edward compares the pros and cons of electronic benefit verification using artificial intelligence, direct connectivity, or data connectivity. He also describes the circumstances where each solution provides the greatest value.

To learn more, download AssistRx’s free eBook: Specialty Drug Patient Support Programs: 2022 Progress Report.

Read on for Edward’s insights.

The Pulse of Electronic Benefit Verification Solutions: Know the Facts
By Edward Hensley, Chief Commercial Officer, AssistRx

Improving price transparency for patients and healthcare providers (HCPs) is a constant priority for life sciences organizations. Unfortunately, only eight percent of prescribers report that it’s somewhat or very easy to access patients’ out-of-pocket (OOP) costs.

Further, only 21% of HCPs can accurately estimate a patient’s OOP drug cost when given all necessary information about product price and patient plan. This signifies that HCPs are looking to life sciences organizations to deliver benefit coverage information not only in an accurate and timely manner, but also in an easily comprehendible format.

Patient support providers (vendors) often generate electronic benefit coverage information via artificial intelligence or direct/data connectivity. Here is a pulse of how each method is used in benefit verifications (BVs) today and how they can impact your program.


Artificial intelligence (AI) is the theory/development of systems that perform tasks normally requiring human intelligence. Using algorithms, AI can deliver accurate information, but it requires a significant amount of historical data to do so. Here are pros, cons and use cases for performing electronic BVs via AI.

  • Delivers immediate information
  • Automates repetitive tasks
  • Identifies and predicts trends to create personalized communications
  • Predictions are based on historical data, not real-time data.
  • May produce skewed results if product- and patient-specific coverage trends have recently changed
  • Not effective at delivering accurate and comprehensive information in instances with sparce historical data and/or current digital data
  • Many technologies are misrepresented as AI.
Use Cases:
  • AI’s conjectural nature hinders its ability to provide accurate product- and patient-specific coverage information. Thus, it’s more effectively applied in situations that do not require comprehensive and precise information (e.g., adherence solutions).
  • AI can support you in tailoring your patient adherence strategy at the individual level, and can even evolve with your patients throughout their journey.

Unlike AI, direct connectivity uses application programming interfaces (APIs), so multiple systems can exchange information in real time. Using APIs, vendors can connect directly to payers/PBMs, clearinghouses and other data sources to gain coverage information. Here are pros, cons and use cases for performing electronic BVs via direct connectivity.

  • Delivers accurate data directly from the source and in real time
  • Returns patient coverage, OOP cost, drug access restrictions (e.g., step edits), coverage alerts (e.g., age limit), fill options, formulary status, employer and more
  • Generates product-, plan- and patient-level prior authorization (PA) information, including whether a PA is required and whether the patient has an active PA on file
  • Provides monitoring and reporting, improving continuity of care
  • Requires significant reach among data sources to deliver accurate and comprehensive information
  • Not all payers have electronic connectivity; thus, manual intervention may be needed.
  • Many electronic BV/Real-time Benefit Check (RTBC) solutions only offer plan-level data, not patient-level data.
  • Most electronic RTBC solutions show the HCP alternatives to the prescribed medication.
Use Cases:
  • HCPs can self-serve to obtain patient coverage information in real time via channels including specialty therapy initiation platforms, HCP engagement websites or as widgets on the brand’s existing website. You should seek a partner that can place ownership of this technology in either their user interface (UI) or your UI. Additionally, your vendor should present only relevant data to the HCP and in an intuitive, digestible format.
  • Vendor hub staff can also leverage this technology to obtain patient coverage information at the point of prescription as well as ongoing (e.g., automated batch reverifications). Your vendor should be able to implement this technology in insourced, hybrid and outsourced hub models.
  • Pharmacies can also use this technology, which is key for brands having high direct-to-pharmacy prescriber populations and/or when the brand does not have a hub.

For medical benefit products, vendors should leverage electronic Medical BV (e-MedBV). While medical benefit information is less digitally accessible than pharmacy benefit information, real-time data connectivity is still a more accurate method than algorithmic conjecture.

  • Delivers accurate data directly from the source and in real time
  • Immediate, accurate coverage information reduces risk for the HCP office
  • Returns payer/plan name and type; member ID; group ID; relationship; effective and termination dates; family/individual deductible, year to date, per year and remaining; and family/individual OOP, year to date, per year and remaining
  • Not all payers and data sources have electronic capabilities for medical benefit products; thus, some manual intervention may be needed.
  • Leveraging multiple data sources is key.
Use Cases:
  • HCPs can self-serve to obtain immediate patient coverage information via specialty therapy initiation platforms. Again, your vendor should present only relevant data to the HCP and in an intuitive, digestible format.
AssistRx delivers real-time, up-to-date and comprehensive digital pharmacy and medical BVs through direct connectivity and/or data connectivity. Our Advanced Benefit Verification solution goes above and beyond other electronic RTBC solutions to provide immediate and comprehensive patient coverage results for all pharmacy benefit therapies. Our e-MedBV solution also pulls real-time, comprehensive medical benefit coverage information using multiple data sources. Both solutions return product-, plan- and patient-specific coverage information in under 30 seconds.

Deploying this market-leading technology isn’t enough to differentiate today’s brands. Patients and HCPs look to life sciences organizations for more support than ever before—access, coverage navigation, affordability, education and adherence. You need a strategic partner with nimble and interoperable technology and the expertise to deploy solutions that address evolving market needs. Learn more about AssistRx solutions in our eBook: Specialty Drug Patient Support Programs: 2022 Progress Report.

Sponsored guest posts are bylined articles that are screened by Drug Channels to ensure a topical relevance to our exclusive audience. These posts do not necessarily reflect our opinions and should not be considered endorsements. To find out how you can publish a guest post on Drug Channels, please contact Paula Fein (

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