Payer Intelligence: How Can It Be Combined With Technology to Enhance Patient Access?

Scott Dulitz, Chief Strategy Officer at Mercalis (formerly TrialCard), discusses how combining payer intelligence with market-leading technology can enhance patient access. Mercalis (formerly TrialCard) recently acquired Policy Reporter, a healthcare software solutions company that provides payer intelligence to the biopharmaceutical, medical device, and diagnostics industries. To learn more, schedule a demo of Policy Reporter or contact Scott (scott.dulitz@mercalis.com).

The healthcare industry is entering an unprecedented era of medical innovation with several recent approvals for curative cell and gene therapies, novel digital therapeutics, and market-shifting biosimilars. In parallel with these medical innovations, coverage is also shifting from fee-for-service to value-based, pay-for-performance. These industry megatrends accentuate an already complex landscape and underscore the growing importance of the role technology and payer intelligence plays in supporting patient access.

Payer Intelligence Is Highly Fragmented and Constantly Changing

Payer intelligence is a nebulous concept and can be comprised of many disparate and highly fragmented information sources like coverage and payment policies, formulary lists, coverage criteria such as step-edits and prior authorizations, coding guidelines, and fee schedules. Most of these source documents can be found in the public domain, but they are typically buried deep within the bowels of thousands of payers’ and PBMs’ web sites.

While it can be extremely difficult to locate these documents, it is even more challenging to interpret them and understand specific references to plan types and coverage codes in a manner that is meaningful to patient access. Not only does the content of these documents lack standardization, but the electronic format in which they are published varies from payer to payer, further complicating the process of capturing and collating this important information.

As regulatory agencies have accelerated the approval of new medical innovations, health plans and benefit administrators have increased the frequency with which they are creating and revising policies to address coverage for these new products and indications. According to a recent AMA survey, 88% of physicians report that PA burdens have increased over the last five years while CMS has allowed for the expanded use of step edits in both Medicare Advantage and Part B.

The increasing prevalence of newly-published policies and coverage criteria, coupled with the frequency in which these payer documents are being revised, further emphasizes the need for a centralized knowledge base that provides real-time payer intelligence. Policy Reporter’s PolicyCore subscription solves this problem by providing real-time email alerts and on-demand access to a searchable database with hundreds of thousands of payer intelligence resources in an easy-to-use web-based application.

Utilizing Technology to Source, Mine, And Extract Payer Intelligence

With over 900 healthcare insurance companies administering thousands of plans, it is impossible for hub programs to manually track and stay on top of all the published policies and coverage criteria for the products they support. This is where technology, like Policy Reporter’s Bumblebee software, can help bridge the gap. Bumblebee’s patented algorithms have automated the real-time monitoring, collection, and indexing of most payer and PBM web sites to ensure manufacturers remain aware of the policy changes that directly impact patient access to their products and services.

While utilizing technology to aggregate and monitor payer documents is essential, the promise of artificial intelligence (AI) to mine these documents and extract relevant coverage information is where the true value is unlocked. Similar to how payers are utilizing AI for claims management, Policy Reporter is leveraging its patent-pending AI algorithms to extract formulary data, coding, and coverage criteria into structured, searchable data fields. This structured information is even more useful than the source documents to hub case managers who are utilizing it to secure patient access. Furthermore, enriching this payer intelligence with other third-party data sources such as pricing files, NDC crosswalks, and compendia listings allows for an even deeper analysis of how products are accessed and covered.

Integrating Payer Intelligence and Technology to Enhance Patient Access

In order to impact patient access on a broader scale, technology integrations must be developed to deploy payer intelligence within hub case management systems, healthcare provider portals, and e-prescribing/EHR systems. HHS recently finalized two new interoperability and patient access rules that should lay the foundation for accelerating these crucial technology integrations.

Mercalis (formerly TrialCard) is currently developing an integration with Policy Reporter that will enable a hub case manager to electronically link a patient’s insurance coverage to the specific medical policy and prior authorization form/criteria for their prescribed product and condition. This type of integration not only enhances the accuracy of a benefit investigation, but can also streamline the communication between the hub and payer, resulting in increased speed to therapy. The hub can also establish credibility and build confidence with the patient’s healthcare provider by referencing the applicable payer policy and coverage criteria in the associated summary of benefits.

At Mercalis (formerly TrialCard) and Policy Reporter, we are experts at using payer intelligence to improve patient access, and we are committed to partnering with our hub clients to deploy this expertise into their programs.

For more information about Mercalis (formerly TrialCard) or Policy Reporter, please email Scott Dulitz, Mercalis' (formerly TrialCard) Chief Strategy Officer, at scott.dulitz@mercalis.com.