Granted Patent B1

US 12,229,834 · App. 17/676,437 · Granted Feb 18, 2025

Inventors: Phillip Draa (Atlanta, GA); Jared Burdine (Dunwoody, GA); John Giglio (Brookhaven, GA)

Assignee: MCKESSON CORPORATION

G06Q40/08G06Q30/0283

Abstract

Claims (54)

1. An apparatus comprising at least one processor and at least one memory including computer program code, the at least one memory and the computer program code configured to, with the at least one processor, cause the apparatus to at least:

receive, at a service provider computer and from a pharmacy computer, an indication of a prescription transaction comprising a patient identifier identifying a patient and a prescription identifier identifying a drug; and

in real-time or near real-time relative to receiving the indication of the prescription transaction, and by the service provider computer:

access an alternative cost data source to determine an alternative cost of the drug available via an alternative system associated with a government-sponsored payer;

transmit a prescription claim associated with the prescription transaction to an adjudication computer identified from a plurality of adjudication computers based on insurance information provided in the prescription transaction;

receive an adjudicated prescription claim associated with the prescription transaction, the adjudicated prescription claim comprising a co-pay amount;

determine a preliminary remaining patient pay amount by applying a predefined target adherence rate to a price sensitivity model;

determine a preliminary credit amount as the co-pay amount minus the preliminary remaining patient pay amount determined by applying a predefined target adherence rate to the price sensitivity model;

determine that the preliminary credit amount would result in a payer cost that is lower than the alternative cost of the drug available via the alternative system;

in response to determining that the preliminary credit amount would result in a payer cost that is lower than the alternative cost of the drug available via the alternative system, adjust the preliminary credit amount by applying a predefined target adherence rate to the price sensitivity model, wherein the preliminary credit amount is adjusted to a credit amount that would result in a payer cost that is greater than or equal to the alternative cost;

determine a remaining patient pay amount by applying the credit amount to the preliminary credit amount determined based on at least the price sensitivity model;

in response to determining the remaining patient pay amount based at least on the price sensitivity model, reformat the adjudicated prescription claim to a format that includes the remaining patient pay amount and the credit amount, and that is readable by the pharmacy computer; and

cause transmission of the adjudicated prescription claim including the remaining patient pay amount and the credit amount to the pharmacy computer.

2. The apparatus of claim 1 , wherein the alternative cost of the drug is determined by accessing historical data.

3. The apparatus of claim 1 , wherein the preliminary credit amount is calculated in order to improve adherence rates.

4. The apparatus of claim 1 , wherein the alternative system is a government funded system.

5. The apparatus of claim 1 , wherein the at least one memory and the computer program code are further configured to, with the at least one processor, cause the apparatus to at least:

cause transmission of the credit amount to at least one of the pharmacy computer or a third party computer.

6. A method comprising:

receiving, at a service provider computer and from a pharmacy computer, an indication of a prescription transaction comprising a patient identifier identifying a patient and a prescription identifier identifying a drug; and

in real-time or near real-time relative to receiving the indication of the prescription transaction, and by the service provider computer:

accessing an alternative cost data source to determine an alternative cost of the drug available via an alternative system associated with a government-sponsored payer;

transmitting a prescription claim associated with the prescription transaction to an adjudication computer identified from a plurality of adjudication computers based on insurance information provided in the prescription transaction;

receiving an adjudicated prescription claim associated with the prescription transaction, the adjudicated prescription claim comprising a co-pay amount;

determining a preliminary remaining patient pay amount by applying a predefined target adherence rate to a price sensitivity model;

determining a preliminary credit amount as the co-pay amount minus the preliminary remaining patient pay amount determined by applying a predefined target adherence rate to the price sensitivity model;

determining that the preliminary credit amount would result in a payer cost that is lower than the alternative cost of the drug available via the alternative system;

in response to determining that the preliminary credit amount would result in a payer cost that is lower than the alternative cost of the drug available via the alternative system, adjusting the preliminary credit amount by applying a predefined target adherence rate to the price sensitivity model, wherein the preliminary credit amount is adjusted to a credit amount that would result in a payer cost that is greater than or equal to the alternative cost;

determining a remaining patient pay amount by applying the credit amount to the preliminary credit amount determined based on at least the price sensitivity model;

in response to determining the remaining patient pay amount based at least on the price sensitivity model, reformatting the adjudicated prescription claim to a format that includes the remaining patient pay amount and the credit amount, and that is readable by the pharmacy computer; and

causing transmission of the adjudicated prescription claim including the remaining patient pay amount and the credit amount to the pharmacy computer.

7. The method of claim 6 , wherein the alternative cost of the drug is determined by accessing historical data.

8. The method of claim 6 , wherein the preliminary credit amount is calculated in order to improve adherence rates.

9. The method of claim 6 , wherein the alternative system is a government funded system.

10. The method of claim 6 , further comprising:

causing transmission of the credit amount to at least one of the pharmacy computer or a third party computer.

11. A computer program product comprising at least one non-transitory computer-readable storage medium having computer-executable program code instructions stored therein, the computer-executable program code instructions comprising program code instructions to:

receive, by a service provider computer and from a pharmacy computer, an indication of a prescription transaction comprising a patient identifier identifying a patient and a prescription identifier identifying a drug; and

in real-time or near real-time relative to receiving the indication of the prescription transaction:

access an alternative cost data source to determine an alternative cost of the drug available via an alternative system associated with a government-sponsored payer;

transmit a prescription claim associated with the prescription transaction to an adjudication computer identified from a plurality of adjudication computers based on insurance information provided in the prescription transaction;

receive an adjudicated prescription claim associated with the prescription transaction, the adjudicated prescription claim comprising a co-pay amount;

determine a preliminary remaining patient pay amount by applying a predefined target adherence rate to a price sensitivity model;

determine a preliminary credit amount as the co-pay amount minus the preliminary remaining patient pay amount determined by applying a predefined target adherence rate to the price sensitivity model;

determine that the preliminary credit amount would result in a payer cost that is lower than the alternative cost of the drug available via the alternative system;

in response to determining that the preliminary credit amount would result in a payer cost that is lower than the alternative cost of the drug available via the alternative system, adjust the preliminary credit amount by applying a predefined target adherence rate to the price sensitivity model, wherein the preliminary credit amount is adjusted to a credit amount that would result in a payer cost that is greater than or equal to the alternative cost;

determine a remaining patient pay amount by applying the credit amount to the preliminary credit amount determined based on at least the price sensitivity model;

in response to determining the remaining patient pay amount based at least on the price sensitivity model, reformat the adjudicated prescription claim to a format that includes the remaining patient pay amount and the credit amount, and that is readable by the pharmacy computer; and

cause transmission of the adjudicated prescription claim including the remaining patient pay amount and the credit amount to the pharmacy computer.

12. The computer program product of claim 11 , wherein the alternative cost of the drug is determined by accessing historical data.

13. The computer program product of claim 11 , wherein the preliminary credit amount is calculated in order to improve adherence rates.

14. The computer program product of claim 11 , wherein the alternative system is a government funded system.

15. The computer program product of claim 11 , wherein the computer-executable program code instructions further comprise program code instructions to:

cause transmission of the credit amount to at least one of the pharmacy computer or a third party computer.

Assignments (1)

Continuity (1)

References Cited (400)