How to Use Clinical Decision Support Systems for Prescription Reimbursement

  • Clinical Decision Support Systems to Increase Prescription Reimbursements

How to Use Clinical Decision Support Systems for Prescription Reimbursement

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The  Affordable Care Act has led to an increase in the number of people with access to the US healthcare system, which in turn, has increased the number of prescriptions written for common conditions. There is an all-too-common frustration among primary care physicians that are prescribing medications they believe will best benefit their patients, only to find out that the drugs will not be covered by their insurance. This leads to either changing the patient to an inferior covered medication or filling out prior authorization forms, making numerous phone calls, and pleading with the insurance company to cover the medicine that would provide the best benefit to the patient.

Using Clinical Decision Support Systems To Increase Insurance Prescription Coverage

A 37-year old female with history of allergic rhinitis is having a difficult start to the Spring allergy season. While an intranasal steroid and oral antihistamine combination has worked well in the past, now her symptoms are worsening.  Her primary care physician would like to change her to a combination intranasal steroid and intranasal antihistamine but her insurance will not cover the change.  Without using an evidence-based algorithm,  prior authorization forms would be completed and then office staff and physicians would often have to try and persuade the insurance company to provide coverage. By running the Allergic Rhinitis Severity Score algorithm, a physician, or dedicated staff member can reference an evidence-based scoring system and inform the insurance company that with worsening symptoms despite current appropriate treatment, this new medication should be covered. Many of my colleagues can attest, when evidence-based studies are referenced to support a physician’s reason for prescribing a new medication, the medicine is covered at a higher rate.

Physicians can get reimbursed more easily for the prescription drugs they prescribe to their patients by relying on Medal’s vast collection of clinical decision tools available via the web or via our iOS app.  When physicians are able to reference the best evidence-based algorithms to make better assessments, they improve the likelihood of treatment plans being covered by a patient’s insurance. Additionally, with the increasing numbers of emergency department visits  in the second year of the Affordable Care Act, emergency medicine and primary care physicians are also being urged to decrease orders for unnecessary tests, which means they’ll need to convince an insurance company to cover a prescription with fewer test results.

Enabling patients to receive coverage for superior medications is one step towards improving health.  Other ways, such as  incorporating wearable data into patient charts can also ensure that medication treatment plans are being followed and symptoms are improving even between office visits.  As we venture towards the digitization of healthcare, we should seek out technologies that will help us improve patient care and reduce costs.  We can give patients more access to the prescription medications they need by combining the authority of evidence-based medicine with technology.  The clinical decision support system offered by Medal gives physicians immediate, 24/7 digital access to the evidence-based medical algorithms they need to substantiate their diagnoses and treatment plans, provide better care, and achieve better outcomes.


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2016-12-15T10:28:00+00:00

About the Author:

Dr. Chad Rudnick, MD, FAAP is a board-certified pediatrician in Boca Raton, FL. A proponent of incorporating medical technology into his practice, Dr. Rudnick uses telemedicine and medical algorithms from The Medical Algorithms Company in his daily practice to better serve his patients and their families. An accomplished medical writer, he maintains a popular pediatric blog, All Things Pediatric, and has written for numerous online and print publications including KevinMD.com.