NewgenOne Software for PBMs

NewgenOne Software to for PBMs – Document Management, Storage and CAG

What is Pharmacy Benefit Management (PBM)

Pharmacy Benefit Managers (PBMs) are third-party administrators that manage prescription drug benefits on behalf of health insurers, Medicare Part D drug plans, large employers, and other payers. Their primary role is to negotiate with drug manufacturers and pharmacies to control drug spending, aiming to reduce costs and improve patient outcomes.

Core Functions and Workflows of PBMs

• Claims Processing: Handling the administrative aspects of prescription drug claims, including eligibility verification and payment processing.
• Drug Utilization Review: Monitoring prescription patterns to ensure appropriate medication use and prevent fraud or abuse.
• Formulary Management: Developing and maintaining lists of covered medications (formularies) to encourage the use of effective and affordable drugs.
• Negotiating Discounts and Rebates: Securing price concessions from drug manufacturers and pharmacies to lower costs for payers and patients.
• Pharmacy Network Management: Establishing networks of pharmacies to provide convenient access to medications for members.

Market Size and Leading Players

The PBM market has experienced significant growth over the past decade. In 2023, the global PBM market was valued at approximately USD 540.32 billion and is projected to reach USD 897.63 billion by 2032, exhibiting a compound annual growth rate (CAGR) of 5.8% during the forecast period.

The U.S. market is particularly dominant, accounting for a substantial share of the global PBM industry. In 2023, the U.S. PBM market was valued at USD 523.96 billion, representing 96.97% of the global market.

The industry is highly concentrated, with the top three PBMs—CVS Health's Caremark, Cigna's Express Scripts, and UnitedHealth Group's OptumRx—collectively managing a significant portion of prescription drug claims. CVS Health holds a 21.3% market share, followed by Express Scripts at 20.8% and OptumRx at 17.1%.

Source: FierceHealthcare

Technological Infrastructure of PBMs

PBMs rely on sophisticated technological infrastructures to manage their complex operations efficiently. Key components of their tech stack include:

• Claims Processing Systems: Automated platforms that handle prescription claims in real-time, ensuring accurate eligibility verification and payment processing.
• Data Analytics Tools: Advanced analytics platforms to monitor drug utilization, assess patient adherence, and identify cost-saving opportunities.
• Electronic Prescribing (e-Prescribing) Systems: Facilitating seamless communication between prescribers and pharmacies to enhance prescription accuracy and reduce errors.
• Patient Management Portals: Web-based interfaces that allow patients to manage their prescriptions, access medication information, and receive reminders.
• Security and Compliance Frameworks: Robust systems to ensure data privacy and adherence to regulatory standards such as HIPAA.

Enhancing PBM Operations with NewgenONE LowCode, AI Powered Software

NewgenONE is a comprehensive digital transformation platform that integrates Enterprise Content Management (ECM), Business Process Management (BPM), and Customer Communication Management (CCM) capabilities. By leveraging NewgenONE, PBMs can optimize their operations in several ways:

• Process Automation: Automate complex, content-driven, and customer-engaging business processes to improve efficiency and reduce operational costs.
• Dynamic Case Management: Manage case-related content and communications in an intelligent and dynamic environment, enabling PBMs to respond effectively to unanticipated scenarios.
• Business Rules Management: Configure and manage business rules centrally to ensure agility and compliance in decision-making processes.
• Omnichannel Customer Engagement: Deliver consistent and personalized communications across multiple channels, enhancing member satisfaction and engagement.
• Robotic Process Automation (RPA): Integrate RPA to handle repetitive tasks, such as claims processing and data entry, thereby reducing manual effort and minimizing errors.

Addressing Complaints, Appeals, and Grievances (CAG) via Newgen's Solution

Effective management of complaints, appeals, and grievances is crucial for PBMs to maintain compliance with regulatory standards and ensure member satisfaction. Newgen offers a Digital Appeals and Grievances solution, powered by low-code and AI, which ensures prompt resolution and compliance with state and CMS guidelines.

Source: Newgen

Key features include:

• Efficient Case Management: Detect and flag duplicates to prevent fraud and speed up resolutions. Automate case allocation to optimize bandwidth. Manage escalations, prioritize cases, and extend case timelines as necessary.
• Robust Integration: Integrate with other applications and claims systems. Validate data against key data sources to ensure accuracy and compliance.
• Variance & Reconciliation Screening: Maintain a well-organized directory of providers within the network for superior member experience and ensure compliance for marketing materials and the “No Surprises Act.”

By implementing Newgen's CAG solution, PBMs can streamline their processes, ensure compliance, and enhance member satisfaction.

Conclusion

Pharmacy Benefit Managers (PBM) play a crucial role in the healthcare ecosystem by managing prescription drug benefits and striving to control costs. As industry continues to evolve, embracing advanced technologies becomes imperative. Platforms like NewgenONE offer PBMs to enhance operational efficiency, ensure compliance, and deliver superior member experiences, thereby solidifying their position in a competitive market. Talk to us for how GHIT Digital can help implement NewgenOne Software to help PBMs.

About GHIT Digital

GHIT Digital ( https://ghit.digital/) is a domain focused, future ready, Enterprise Software Product Implementation, IT Services & Digital Transformation firm. We are Minority and Women Owned (MWOB) small business from New Jersey, USA. Diversity, Inclusion, and Growth is our Mantra. Team GHIT works on strategic IT Projects for Government (G); HealthCare (H); Insurance (I); and Technology (T) clients, thus the brand GHIT. We are nimble, scalable and sell & deliver with Platform Partners & Delivery Partners. Our niche capabilities include Agile Project Management, Infrastructure Services, Data Services, Cloud native Data and Implementation, Integration, Migration, & Optimization of AI Powered, LowCode NewgenOne EDM, BPM, CCM, ANG and PLM Software Products & Platforms.

Contact US

MonMass, Inc. (the legal name of GHIT Digital) will work on your strategic IT Projects or Consulting requirements (NAICS codes 541511 / 541512 / 541330 / 541618). Feel free to call 201.792.8924 or 646.734.6482 or write to me at Monika@GHIT.digital for no obligation discovery conversation. You are welcome to share your RFPs/RPQs for us to review and respond on time.

Monika Vashishtha, MBA, ITIL, PMP

President

https://ghit.digital I Monika@GHIT.digital

Government | Health | Insurance | Tech

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