Prime Therapeutics Puts Compliance at its Core with SAI360

Case study at-a-glance

Prime Therapeutics provides pharmacy benefit management services for health plans, employers and government programs. It is collectively owned by 19 Blue Cross and Blue Shield plans, subsidiaries, or affiliates of those plans. It manages the entire administrative lifecycle of pharmacy benefits, from when a member is given a prescription to when a pharmacy fills it.

Ryan Sloneker is the Compliance Systems & Materials Manager at Prime Therapeutics. This role has expanded as the company has shifted its approach to compliance. In 2011, Prime Therapeutics committed to compliance across the entire organization.

“The management team understood that compliance couldn’t be the responsibility of a few dedicated roles and instead had to be part of the entire organization’s fabric with a corresponding depth and breadth,” explained Ryan. “That depth and breadth of compliance is anchored in SAI360.”

Ryan’s role shifted from a dedicated system administrator to managing compliance across Prime Therapeutics in line with its technology approach. “Our approach to technology is agile inspired, so applications are centralized with teams having access and autonomy.”

Prime Therapeutics uses several SAI360 modules on the SAI360 platform, including Policy Manager, Privacy Breaches, Incident Manager and Third Party Risk Management.

“We use Policy Manager extensively,” said Ryan. “Policy management is crucial–policies need to be kept current and updated with regulations, easy to retrieve, and automated with workflows to simplify policies’ creation, review, approval and attestation. Like other healthcare organizations, we have many moving parts, and tracking and monitoring policies is essential for compliance.”

He added, “All our corporate policies are within SAI360 Policy Manager, so it’s a birthright tool–every one of our 3,000 or so employees has access to SAI360 from the moment they join. Policy Manager is linked to our intranet, so policies are easily accessible.”

Privacy management is another critical area. “No healthcare organization can afford to ignore privacy management,” said Ryan. “SAI360 gives us the capacity to track disclosures, manage investigations, log assessments, monitor status and produce relevant reports for internal and external needs. The SAI360 software allows us to handle a huge volume of documents across extensive processes.”

“We have seen a dramatic change in incident management and how we can use SAI360 Incident Manager,” said Ryan. “SAI360’s new architecture, Foundational Architecture 3 (FA3), gave us even more functionality, allowing us to do remarkable things within the Incident Manager module without having to code or embark on a huge project. For example, we can use parent-child relationships in a unique way that supports how we handle records and relationships with bodies like Medicare and Medicaid.”

SAI360 gives us the capacity to track disclosures, manage investigations, log assessments, monitor status and produce relevant reports for internal and external needs. The SAI360 software allows us to handle a huge volume of documents across extensive processes.

Ryan continued, “SAI360 allows us to create parent-child relationships in other ways to suit our business. For example, we can set up a contract and contract addendum or incident and investigation. We can use SAI360 to manage third-party risk when vendors work for Medicaid and handle contract objects and letters of authority. Our workflow is complex and eloquent–and, thanks to SAI360, all created without the need to code–it’s mesmerizing, capturing the complexity of our business with controls, rules and automated workflows.”

Prime Therapeutics also utilizes features in SAI360 Incident Manager to track clinical reviews, error assessments, and performance coaching. These features support Prime’s Quality Audit process, part of its claims processing. Ryan explains, “We currently process more than 270 million claims a year. All our processes, investments and technologies, including SAI360, are selected to handle the claims data’s criticality, volume and security.”

HOW HAS SAI360 HELPED PRIME THERAPEUTICS SCALE ITS BUSINESS?

“SAI360 has certainly increased efficiency,” said Ryan. “It manages, sorts, filters and automates the volume of data we handle and allows us to scale–all without needing to code.”

Ryan concludes, “At the end of the day, you want software that will simplify the complexities, keep you on top of changing regulations, protect privacy, and streamline processes–delivered by a team that understands your market and always has your back, which is why we work with SAI360.”

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