Streamlining Prior Authorization
Sam Rajan was working as a pharmacist for a pharmacy benefits manager (PBM) and frequently witnessed patients with major illnesses abandon their request for prescription therapy because they did not know how to complete prior authorization (PA). He spoke to patient support groups to understand the root cause. It was simple. They were frustrated because they thought that they did not have coverage. In response to their frustration, Sam co-founded CoverMyMeds in 2008, a pharmacy software company that streamlines the PA approval process.
Today, CoverMyMeds is the leader in electronic prior authorization (ePA), assisting physicians and pharmacists in completing PA requests for any medication and all health insurance plans online. Traditionally, this had been a laborious process involving phones and fax machines. Currently, the technology integrates with nearly 47,000 pharmacies, more than 500 electronic health record (EHR) systems and payers, which represent nearly 75% of U.S. prescription volume. With more than a million PA requests submitted through their portal monthly, CoverMyMeds is the only vendor using the ePA NCPDP SCRIPT Standard at scale.
CoverMyMeds partners with health insurance companies and providers while selling support services to manufacturers and other healthcare companies to improve patient access to medications. After eight years in operation, CoverMyMeds employs more than 300 people and regularly doubles its sales and size of its staff annually.
In 2015, CoverMyMeds announced several major integrations, including one with Epic, which is the EHR system used by the Cleveland Clinic and MetroHealth, and another with Practice Fusion, a cloud-based EHR for doctors and patients. The latter enables Practice Fusion’s 110,000 medical professionals who manage more than 100 million patient records to submit ePA for medications to health insurance plans within their existing workflow. “Prior authorizations are considered the single most tedious process in a doctor’s workflow,” says Ryan Howard, Founder and CEO of Practice Fusion. This allows HCPs to “focus on what they are trained to do, which is spending more time serving their patients.”
Prior to launching CoverMyMeds, Sam headed clinical operations at MemberHealth where the organization won many clinical awards and was the No. 1 ranked company in the Inc. 5000 in 2007.