DPRx signs first license for Online, Real-Time Insurer Authorization system

Apr 8 2013

DPRx's CEO, John Discola , announced the signing of the first license for PRO/3G its recently released Online, Real-Time Insurer Authorization system. PRO/3G offers a major technology breakthrough that is designed to produce substantial cost containment savings and huge cost cutting of the administrative expense associated with adjudicating ICD/CPT Procedures submitted by healthcare providers seeking insurance benefit authorizations.

This Internet-based solution continues DPRx's pioneering legacy in development of Online, Real-Time, server-based PBM processors dating back to 1988. Several versions of its PBM systems evolved over 25 years with extensive and field-proven cost containment algorithms. These algorithms plus more efficient Procedure evaluation techniques are used in the new DPRx PRO/3G system. It employs ICD9/10 and CPT10 industry standard databases common to today's Procedural adjudications.

The new PRO/3G system replaces the decades-old telephone-based methodology for insurance authorizations of procedures prescribed by Physicians and Specialists serving in an Insurance company provider networks.

This long-awaited Internet paradigm for medical Authorizations replaces today's routine RXs by online, real-time processing directly from the Provider's POS with the same cyberspace efficiency of PBM systems. It minimizes and collapses today's huge labor-intensive telephone inquiry and expensive authorization process for non-routine Procedures. An estimated 80% of all authorization transactions are by these lower-cost procedures common to patient office encounters.

The remaining, much more expensive 20% of transactions (80% of medical costs) ordinarily require direct examination by the insurer's medical professionals to confirm coverage compliance and medical appropriateness. In these cases the PRO/3G system becomes a tool of efficiency for the medical examiners by expediting delivery of required diagnosis reports and associated supporting data and information. A highly efficient and secure data communication process is employed that replaces person-to-person scheduling synchronization of the doctor and the insurer's examiner.

The Prior Authorization transactions, that represent an estimated 80% of procedure costs, relieve both parties from direct person-to-person interaction by telephone and FAX. Authorization responses can now be delivered in minutes or hours rather than days of delay. Oftentimes responses take over a week for an approval.

PRO/3G also provides an in-patient capability by Case-based tracking of serial authorizations common to hospitalizations where all procedures are tabulated and reviewable 24x7 by Internet.

An important feature of the PRO/3G system is customization options provided for inserting intercepts by the Insurer's administrators. Subscribers, Providers and Procedures can be targeted for mandatory direct examination. It is estimated that a major reduction in fraud and abuse is attainable by expediting and optimizing inspection of expensive and complex procedures by freeing professional examiners from routine examination tasks.

Analysis of today's person-to-person Authorization labor costs is estimated to be 8% to 10% of gross procedure benefit costs. Net procedure costs as a portion of overall costs are estimated to represent at least 65% of total operating costs. The savings then represents 12% to 20% of the 65% of procedure costs. Thus the new technology has the potential of improving bottom line Insurance Company operating costs by 8% to 14% when including the inherent fraud and abuse curtailment due to the online, real-time, cost-cutting efficiencies.

PRO/3G's online reporting module can also be employed to track provider over-utilization of imaging and diagnostic testing. Such tracking intercepts can focus on excessive testing and can significantly reduce those costs. This is often cited as being very prevalent in today's litigious environment that fosters over utilization by Doctors acting defensively against malpractice threats.