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Solutions
Description
Compatibility Level
Clients
Use cases
EHR integrations
Client types
Differentiators
Keywords
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Company details
Jump to:
Categories
Solutions
Description
Compatibility Level
Clients
Use cases
EHR integrations
Client types
Differentiators
Keywords
Media
Company details
PAHub™
PAHub™

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PolicyCore
PolicyCore

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Categories

Solutions

Description

Product Description:
PAHub™, is a HITRUST certified solution that puts the tools at your fingertips to streamline and control all clinical, compliance and administrative aspects of Prior Authorization to improve compliance, automation, reduce turn-around times and costs.
About Agadia:

Agadia is a leading healthcare management technology company addressing the evolving needs of the managed care market with a suite of utilization management solutions in electronic prior authorization, MTM, part d star ratings & adherence, and formulary benefit design. Used by the nation’s largest health plans and PBMs, Agadia’s advanced technology solutions help drive operational efficiency, appropriate utilization, compliance, and profitability. For more information, visit www.agadia.com.

Product Description:

Optimize your policy management.

The Most Comprehensive Database

Access the most complete database of live and historical medical and pharmaceutical policies and related documents on the market.

Real-Time Notifications

Stay ahead with email alerts on any changes to medical and pharmaceutical policies by payer and therapy, allowing you to respond swiftly to developments that may impact your stakeholders.

Central Access

Effortlessly search and review Medical & Pharmacy policies, draft policies, prior authorization documents, coding guidelines, reimbursement updates, and more—all in one centralized location.

Comparison View

Easily identify differences between current and historical versions using our intuitive viewer that highlights changes for quick reference.

Research Control

Focus your research by filtering specific payers, plan types, states, therapies, devices, or document types, ensuring you find exactly what you need.

Visit https://www.policyreporter.com/industry/providers/ for more information and a free trial.

About Policy Reporter:

Empower your teams with Policy Reporter's payer documents library, change alerts, and reserach tools. 

Healthcare providers face numerous challenges in navigating the complex U.S. healthcare system:​

  • Keeping up with evolving medical necessity criteria, coverage policies, and billing rules​
  • Understanding and complying with diverse payer policies and prior authorization across commercial and government plans​
  • Efficiently managing revenue cycle processes in a constantly changing reimbursement landscape​
  • Ensuring patient access to necessary care while meeting payer requirements​
  • Minimizing claim denials and optimizing reimbursement​

This causes challenges such as: ​

  • Interpreting and applying complex payer policies consistently across the organization​
  • Reducing administrative burden associated with prior authorizations and claim appeals​
  • Staying current with frequent policy changes that impact reimbursement and patient care​
  • Balancing compliance requirements with operational efficiency​
  • Maximizing revenue while ensuring appropriate utilization of healthcare services​

Policy Reporter empowers healthcare providers to address these challenges by:​

  • Delivering analyst-verified alerts for tracking policy changes customize to your specialties and payer mix​
  • Simplifying access to up-to-date coverage criteria, prior authorization and reimbursement rules​
  • Offering comprehensive research capabilities to comply with key contract and claims rules​
  • Supporting efficient revenue cycle management with targeted insights and tools​

Our solutions reduce administrative burden, streamline reimbursement-related research, and empower your entire team to make informed decisions that improve patient care and financial performance.​​

Compatibility level

Select which hospital or health system you work at and see a personalized compatibility level.

Clients

Select which hospital or health system you work at and see the client list

Use Cases

Description:

Electronic Prior Authorization Process & Automation Software

Improve Clinical Efficiency & Compliance with Agadia’s fully customizable web-based solution, PAHub.

End-to-End Management of Electronic Prior Authorizations

Delivering Electronic Prior Authorization Efficiency & Compliance

As Prior Authorization volumes continue to rise, and as specialty drugs create additional clinical complexities, Health Plans, Pharmacy Benefit Managers (PBMs) and Third-Party Administrators (TPAs) are challenged to adapt while maintaining or improving operational and clinical efficiencies. PAHub, is a HITRUST certified solution that puts the tools at your fingertips to streamline and control all clinical, compliance and administrative aspects of Prior Authorization at the point-of-care to improve compliance, reduce turn-around times and costs.

By leveraging the latest technologies for data mining, data analytics, content management and advanced decision support trees, PAHub, enables customers to automate the end-to-end prior authorization process.

All Lines of Business

Supported across all lines of business (commercial, Medicare, Medicaid, etc.)

All Channels

Available across all channels (electronic prior authorization (ePA), phone, fax, web, e-prescribing, etc.)

All Healthcare Services

Applicable for all healthcare services, all benefit types (pharmacy & medical)

Pediatric use cases:

None provided

Users:

HealthSystem

Description:

Denials Management Team:

Challenge: A sudden increase in denied claims needs to be investigated to determine the root cause.

Use Case: Your denials management team can access the specific payer policy that was in place when the claim was originally filed. This helps verify if a policy change caused the denial and provides the documentation needed for appealing the claim based on historical policy criteria.

 

Prior Authorization Team:

Challenge: Inefficient prior authorization processes lead to delays in patient care and increased administrative burden.

Use Case: Your prior authorization team can use a centralized database with the latest policy requirements for specific treatments. Automated alerts notify your team when payers update their prior authorization criteria, ensuring they have up-to-date information for quicker approvals and fewer delays.

 

Physician Advisors & Utilization Review Team:

Challenge: Aligning clinical recommendations with payer guidelines to avoid conflicts and optimize care delivery.

Use Case: Your physician advisors can review the latest payer policies to ensure that clinical decisions align with coverage criteria. This helps avoid peer-to-peer conflicts with payers and reduces the risk of denied authorizations for medically necessary services.

 

Physicians and Prescribers:

Challenge: Staying informed about changes to medication coverage criteria that could impact prescribing habits.

Use Case: Your physicians can subscribe to alerts for specific medications they frequently prescribe. When a payer updates coverage criteria, your physicians receive notifications, allowing them to adjust prescribing patterns or provide alternative treatment options in real-time.

 

Billing & Coding Teams:

Challenge: Coding errors and outdated billing practices lead to increased claim rejections and delays in reimbursement.

Use Case: Your billing and coding teams can verify the latest policy requirements for specific codes before submitting claims. This ensures compliance with payer rules and reduces the likelihood of claim rejections due to incorrect coding.

 

Contract Management Team:

Challenge: Understanding complex payment rules and negotiating favorable terms with payers.

Use Case: Your contract management team can access historical and current payer policies to gain insights into payment rules and criteria. This information can be used to negotiate more favorable contract terms, ensuring parity and compliance with payer requirements.

 

Case Management & Patient Advocacy:

Challenge: Ensuring patients receive timely and appropriate care while navigating complex payer requirements.

Use Case: Your case managers can quickly look up coverage policies for specific treatments or services needed by patients. This allows them to coordinate care more effectively and advocate for patient access to necessary treatments, even when coverage is uncertain.

 

Compliance Officers:

Challenge: Staying compliant with the constantly changing landscape of payer requirements and avoiding costly penalties.

Use Case: Your compliance officers can rely on automated alerts to track policy updates and changes across multiple payers. This allows them to update internal policies and workflows proactively, reducing the risk of non-compliance.

 

Revenue Integrity Team:

Challenge: Identifying and addressing revenue leakage due to underpayments or incorrect payer policies.

Use Case: Your revenue integrity team can use historical policy data to review denied claims and identify discrepancies in payer reimbursements. This information can be leveraged to pursue underpayment recoveries and prevent future revenue loss.

 

Pharmacy Team:

Challenge: Navigating complex formulary changes that affect patient access to medications.

Use Case: Your pharmacy team can monitor payer formulary updates through alerts, allowing them to adjust their inventory and provide patients with the most up-to-date information on medication coverage and alternatives.

Pediatric use cases:

The same use cases can be applied to your pediatric teams. 

Users:
  • Denials Management Team
  • Prior Authorization Team
  • Physician Advisors & Utilization Review Team
  • Physicians and Prescribers
  • Billing & Coding Teams
  • Contract Management Team
  • Case Management & Patient Advocacy
  • Compliance Officers
  • Revenue Integrity Team
  • Pharmacy Team

EHR Integrations

Integrations:

None provided

EMR Integration & Relevant Hardware:

None provided

EMRs Supported:

None provided

Hardware Compatibility:

None provided

Integrations:

Not applicable

EMR Integration & Relevant Hardware:

Not applicable

EMRs Supported:

Not applicable

Hardware Compatibility:

Desktop, Mobile / Tablet (web optimized)

Client Types

None provided

Differentiators

Differentiators vs EHR Functionality:

None provided

Differentiators vs Competitors:

CONTINUALLY INNOVATING TO MEET INDUSTRY NEEDS

Addressing Electronic Prior Authorization for Drugs Under the Medical Benefit

With an influx of infused medications being administered in physician offices, prior authorizations for drugs billed under the medical benefit are presenting challenges across the industry. While there is an industry NCPDP SCRIPT standard for electronic prior authorization (ePA) for drugs billed under the pharmacy benefit, driving significant ePA volume, an industry standard does not currently exist for drugs under the medical benefit.

The challenge with adopting the NCPDP SCRIPT standard for drugs under the medical benefit is that these medications typically do not go the standard route of provider e-prescribing to a traditional retail or mail-order pharmacy location. Often times, the specialty medications are being purchased by the provider (physician/infusion center) directly from drug distributors and administered in the office setting. As a result, health plans continue to receive the drugs under the medical benefit prior authorization requests via phone, fax, or portal which is placing an enormous administrative burden on the health plans operations team, provider office, and the patient.

Agadia continues to innovate and has addressed these challenges by providing eMPA capabilities to reduce the prior authorization administrative burden through a more efficient channel that increases automation and improves turnaround times. Providers will benefit by quickly being informed whether the drug is under the pharmacy or medical benefit, allowing them to efficiently manage requests. Hub companies will experience improved efficiencies as well such as faster turnaround times for a prior authorization decision, improved patient speed to therapy and better adherence.

LEVERAGE ADVANCED TECHNOLOGIES

Save Valuable Time & Resources with PAHub’s Auto-Decision

PAHub’s Auto-Decision rules engine increases automation be leveraging data mining techniques across enterprise systems data to electronically adjudicate prior authorization requests. Auto-Decision helps a customer to allocate staff to high-touch requests instead of requests that can be adjudicated automatically.

ENGAGE PHARMACIES, MEMBERS & PROVIDERS

In the Prior Authorization and Pre-Certification Process

PromptPA is a self-service, web based solution that enables our customers’ pharmacies, members and providers to request prior authorizations electronically, initiate renewals and check the status of requests using any web browser, reducing operational costs and call volume to Health Plans and Benefit Managers.

Differentiators vs EHR Functionality:

Quick Access!

There is no need to have your IT team plan out a complex EHR integration. Access policies via the easy-to-use portal and recieve alerts directly to your email inbox. 

Our team will quickly set up individual user access with customized alerts. 

Differentiators vs Competitors:

The Most Comprehensive Database

Access the most complete database of live and historical medical and pharmaceutical policies and related documents on the market.

Amazing Customer Support 

Our team will work to ensure you get the most out of your Policy Reporter subscription. We strive to be more than a vendor - we want to be your partner in improving patient access. 

Keywords

Images

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Videos

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Downloads

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Company Details

Founded in 2007

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