Patent Issued for System for pre-adjudicating and modifying data packets in health claim processing system (USPTO 11875415): Flipt LLC

2024 FEB 07 (NewsRx) -- By a News Reporter-Staff News Editor at Insurance Daily News -- Flipt LLC (Jersey City, New Jersey, United States) has been issued patent number 11875415, according to news reporting originating out of Alexandria, Virginia, by NewsRx editors.

The patent’s inventors are Greenblatt, Aaron (Jersey City, NJ, US), Peysekhman, Lev (Freehold, NJ, US).

This patent was filed on March 31, 2023 and was published online on January 16, 2024.

From the background information supplied by the inventors, news correspondents obtained the following quote: “The process of filling a prescription at a pharmacy involves a complicated process involving a well-established infrastructure that involves several entities, in which the pharmacy transmits a data packet defining a prescription that a consumer is requesting to fill and receiving an approval or denial of the request, all within a secure and specialized network (e.g., eRx Network™) for transmitting such prescription claim requests and responses. While various attempts have been made at providing new processes that have the potential of providing savings to consumers on their prescriptions, these processes rely on pharmacies changing their well-established processes and/or changing the underlying infrastructure for processing and adjudicating requests for prescription claims, which limits the desirability, efficiency and accessibility of such solutions. Additionally, many such solutions require a consumer to make the difficult choice of going through the established infrastructure of prescription fulfillment and having their prescription go through their prescription plan of their chosen health benefit plan or trying to find an alternate mechanism for savings that is outside their prescription plan.

“Pharmaceutical prescription costs have been dramatically increasing over the past many years and are expected to continue to do so. Even persons covered by a pharmacy benefit insurance plan (also referred to as a prescription plan or prescription benefit plan herein) and/or health insurance plans continue, year-over-year, to pay increasingly higher prices for each prescription they fill. Prescription costs continue to increase for reasons such as the co-pay amounts escalating, prescriptions not being covered by pharmacy benefit plans or counting towards an insured’s out-of-pocket portion of the plan due to increasing prices even within a pharmacy benefit plan network.

“One reason for the high cost of prescription drugs is that the savings that result from rebate or discount agreements that are entered into between prescription drug manufacturers and Pharmacy Benefit Managers (“PBMs”) or other entities are not nearly often enough passed on to the plan holders/consumers. PBMs are third party administrators of pharmacy benefit plans that work with pharmacies, pharmaceutical drug manufacturers and pharmaceutical benefit plan providers to negotiate discounts and rebates for prescription drugs and process claims for prescription drug claims and reimburse pharmacies for prescriptions filled by the pharmacies. Unfortunately, the end user or consumer that ultimately purchases the prescription drug often does not realize the benefits of any discounts negotiated with the retailers or rebates negotiated with the drug’s manufacturer. Further, PBMs often add significant spreads to the cost of generic prescription drugs; in Applicant’s estimation, generic drugs are marked up nearly 600% on average from the time they leave the manufacturer’s premise until the time they are reimbursed by some combination of plan sponsor and plan member.

“Applicant has recognized that there is a long-standing need for a prescription drug redemption system that results in lower prescription drug prices to ends users or consumers and that works within the framework of the long-standing systems and processes for how prescription drugs are sold by pharmacies and for which pharmacies are reimbursed after filling a prescription. Lower prescription drug costs to consumers will result in various benefits, such as a greater adherence to a medical treatment plan (since many consumers report that the primary reason for not filling or re-filling a prescription is the high cost to the consumer when filling the prescription) and cost savings to employers or other health plan providers. Applicant has further recognized that pharmacies operate within a long-standing prescription redemption infrastructure that should be largely maintained in order to minimize any disruptions or modifications to the systems and processes of the many pharmacies throughout the country that rely on such infrastructure. Accordingly, Applicant has invented embodiments which, working within the current prescription redemption infrastructure relied upon by pharmacies, provides for Applicant’s inventive system to process and modify data packets such that, while allowing a consumer to realize lower prices, results in minimal disruption and/or modification to pharmacies’ current processes such that the insertion of Applicant’s system and processes into the current infrastructure appears essentially transparent to the pharmacies.”

Supplementing the background information on this patent, NewsRx reporters also obtained the inventors’ summary information for this patent: “The filling of prescriptions by consumers is currently a stressful and opaque process for the consumers (the persons for whom the prescriptions are provided by healthcare providers). The costs to consumers and pharmacy benefit providers (whether these be employers, corporate employers, health plans, labor unions, government entities and other organizations, collectively “Pharmacy Benefit Plan Providers” or PBPPs herein; also sometimes collectively referred to as “employers” herein) has been rapidly and continually increasing over many years. In accordance with some embodiments, PBPPs may also include employers or other healthcare benefit plan provider that provide healthcare benefits other than pharmacy benefits (e.g., healthcare provider benefits, treatment or diagnostic test benefits, etc.). The pricing of pharmaceutical drugs (in terms of the price the consumer ends up paying out-of-pocket for obtaining the drug, referred to as a Consumer Price herein) is a convoluted process that involves confidential contracts between the various pharmacies that fill the prescriptions and the Pharmacy Benefit Managers (PBMs) that administer pharmacy benefit plans on behalf of PBPPs, with the result being that the same pharmaceutical drug can have different Consumer Prices at different pharmacies. Under current practices, neither consumers nor PBPPs have ready access to the pricing information for different available pharmacies such that they can effectively accept and lock in a price for filling the prescription drug at a first pharmacy and thus realize the potential cost savings of having a prescription filled at the first pharmacy rather than a second pharmacy. Embodiments described herein provide consumers with an effective mechanism for comparing Consumer Prices at different pharmacies (and, in some embodiments, earning rewards) and obtaining the lowest available price while still going through their health insurance and pharmacy benefit plan such that the Consumer Price they pay is applied towards their deductible.

“It should be noted that under the current prescription drug fulfillment system that involves PBMs managing and facilitating the fulfillment of prescriptions as a middleman between the PBPP, the consumer and the pharmacies, there are different monetary values exchanged between the various involved entities, which further obfuscates to the consumer whether he/she could be paying less for the prescription. The various monetary amounts involved in the fulfillment of a prescription are described below, for purposes of background information that sets forth the need for the invention(s) described herein.

“A first monetary value involved in the fulfillment of a prescription is the monetary value a pharmacy has paid for obtaining the pharmaceutical drug (e.g., directly from the drug manufacturer or from a wholesaler) such that it has it in inventory and available for fulfillment of prescriptions. The monetary value that a pharmacy has paid for obtaining a pharmaceutical drug (whether a generic or brand version) is referred to as a Drug Cost herein.

“A second monetary value involved in the fulfillment of a prescription is the monetary value a pharmacy is paid by a PBM upon filling the prescription. The PBM that administers the consumer’s pharmacy benefit plan on behalf of the consumer’s PBPP has different pricing agreements with different pharmacies (e.g., WALMART™ vs. CVS™). A pricing agreement, that defines prices for different drugs that the PBM will cover and reimburse the pharmacy for, is agreed to between a pharmacy company and a PBM (often referred to as a Pharmacy Participation Agreement, or “PPA” herein). For generic drugs, the pricing agreement typically defines the parameters and aggregate discounts rates that are used to develop the respective Maximum Allowable Cost (“MAC”) for each generic pharmaceutical drug that the PBM will reimburse the pharmacy upon fulfillment of a prescription. Typically, MAC lists are published monthly and show the current MAC value for each generic pharmaceutical drug, per PBM. Sometimes, a pharmacy is reimbursed less than the MAC Pharmacy Reimbursement Amount for the various pharmaceutical drugs dispensed by the pharmacy and for which the pharmacy is reimbursed by the PBM. A Pharmacy Reimbursement Amount for a particular pharmaceutical drug, as the term is used herein unless indicated otherwise, is the monetary value a particular pharmacy is paid by a particular PBM (or the system of the present invention, as described herein) upon fulfillment of a prescription for that pharmaceutical drug (whether it is a MAC list price or otherwise and likely includes a fixed fulfillment fee per prescription).

“The Pharmacy Reimbursement Amounts owed to a pharmacy by a PBM are often provided to a pharmacy in bulk at periodic intervals. For example, once per month or once per fiscal quarter a PBM will transmit payment to a PBM of all the Pharmacy Reimbursement Amounts it owes the pharmacy for prescriptions filled by the pharmacy under a pricing agreement between the PBM and the pharmacy, along with a transaction log that shows the particular Pharmacy Reimbursement Amount owed and what transaction it pertains to. A unique transaction identifier is assigned to a prescription fulfillment request when it is submitted to the PBM by a pharmacy when a consumer is at the pharmacy to fill the prescription and the transaction log references this unique transaction identifier along with the amount being paid to the pharmacy by the PBM for that transaction.”

The claims supplied by the inventors are:

“1. A system for routing pharmacy prescription fulfillment requests, the system comprising: a processor; a non-transitory memory storing a program, the processor operable with the program to: (a) receive, at a device functioning as an alternative pharmacy benefit manager (APBM) and from a pharmacy device via a prescription processing computer network dedicated to processing requests for fulfillment of pharmaceutical prescriptions, a first data, the first data comprising (i) a request for fulfillment of a prescription at a pharmacy corresponding to the pharmacy device; (ii) a first BIN/PCN identifier that had caused the pharmacy to transmit the first data to the system, and (iii) a user identifier identifying a user associated with the request; (b) select one of the following options: (i) fulfilling the prescription based on a first pricing contract previously established with the pharmacy; and (ii) utilizing at least one second pricing contract of at least one of a plurality of third party pharmacy benefit managers for fulfillment of the prescription; © only if option (ii) in (b) is selected, perform (d)-(f), otherwise utilize the first pricing contract for fulfillment of the prescription without transmitting the first data to any of the plurality of third party pharmacy benefit managers for fulfillment of the prescription; (d) identify one of the plurality of third party pharmacy benefit managers, for the fulfillment of the prescription; (e) modify the first data by replacing the first BIN/PCN identifier with a second BIN/PCN identifier that corresponds to the one of the plurality of third party pharmacy benefit managers identified for fulfillment of the prescription, thereby generating a modified first data; and (f) transmit, via the prescription processing computer network, the modified first data to a device of the one of the plurality of third party pharmacy benefit managers identified for fulfillment of the prescription.

“2. The system of claim 1, wherein the processor is further operable with the program to: adjudicate the request for the fulfillment of the prescription in order to verify that the prescription is authorized to be redeemed by the user at the pharmacy; and further modify the first data by including in the modified first data that is transmitted to the one of the plurality of third party pharmacy benefit managers an indication that the prescription is authorized to be redeemed by the user at the pharmacy.

“3. The system of claim 2, wherein the processor being operable with the program to adjudicate the request comprises the processor being operable with the program to: retrieve information corresponding to a pharmacy benefit plan of which the user is a member; and verify that the fulfillment of the prescription by the user at the pharmacy is within at least one rule of the pharmacy benefit plan.

“4. The system of claim 1, wherein the processor is further operable with the program to: determine an out of pocket cost to be paid by the user for the fulfillment of the prescription at the pharmacy; and further modify the first data by including in the modified first data that is transmitted to the one of the plurality of third party pharmacy benefit managers an indication of the out of pocket cost.

“5. The system of claim 4, wherein the processor is further operable with the program to: charge the out of pocket cost to a financial account associated with the user.

“6. The system of claim 1, wherein the processor is further operable with the program to: determine a reward to be provided to the user for the fulfillment of the prescription at the pharmacy; and cause the reward to be provided to the user.

“7. The system of claim 6, wherein the processor is further operable with the program to: determine that the reward to be provided to the user comprises a payment to be made to the user by the pharmacy; and wherein modifying the first data comprises adding to the first data an indication of the payment to be provided to the user by the pharmacy upon a fulfillment of the prescription.

“8. The system of claim 1, wherein the processor being operable with the program to select one of a plurality of third party pharmacy benefit managers comprises: retrieving, from a database, the one of the plurality of third party pharmacy benefit managers identified for the fulfillment of the prescription by the user prior to receiving the first data.

“9. The system of claim 1, wherein the processor being operable with the program to select the one of the plurality of third party pharmacy benefit managers comprises: identifying, after receiving the first data, a set of available prices for the prescription, each price of the set of prices corresponding to a different one of the plurality of third party pharmacy benefit managers; and selecting the different one of the plurality of third party pharmacy benefit managers that corresponds to a price satisfying at least one criteria.

“10. A non-transitory computer-readable medium storing instructions for directing a processor to perform a process, the process comprising: (a) receiving, at a device functioning as an alternative pharmacy benefit manager (APBM) and from a pharmacy device via a prescription processing computer network dedicated to processing requests for fulfillment of pharmaceutical prescriptions, a first data, the first data comprising (i) a request for fulfillment of a prescription at a pharmacy corresponding to the pharmacy device; (ii) a first BIN/PCN identifier that had caused the pharmacy to transmit the first data to the system, and (iii) a user identifier identifying a user associated with the request; (b) selecting one of the following options: (i) fulfilling the prescription based on a first pricing contract previously established with the pharmacy; and (ii) utilizing at least one second pricing contract of at least one of a plurality of third party pharmacy benefit managers for fulfillment of the prescription; © only if option (ii) in (b) is selected, performing (d)-(f), otherwise utilize the first pricing contract for fulfillment of the prescription without transmitting the first data to any of the plurality of third party pharmacy benefit managers for fulfillment of the prescription; (d) identifying one of the plurality of third party pharmacy benefit managers, for the fulfillment of the prescription; (e) modifying the first data by replacing the first BIN/PCN identifier with a second BIN/PCN identifier that corresponds to one of the plurality of third party pharmacy benefit managers identified for fulfillment of the prescription, thereby generating a modified first data; and (f) transmitting, via the prescription processing computer network, the modified first data to a device of the one of the plurality of third party pharmacy benefit managers identified for fulfillment of the prescription.

“11. The non-transitory computer-readable medium of claim 10, wherein the process further comprises: adjudicating the request for the fulfillment of the prescription in order to verify that the prescription is authorized to be redeemed by the user at the pharmacy; and further modifying the first data by including in the modified first data that is transmitted to the one of the plurality of third party pharmacy benefit managers an indication that the prescription is authorized to be redeemed by the user at the pharmacy.

“12. The non-transitory computer-readable medium of claim 11, wherein the process further comprises: retrieving information corresponding to a pharmacy benefit plan of which the user is a member; and verifying that the fulfillment of the prescription by the user at the pharmacy is within at least one rule of the pharmacy benefit plan.

“13. The non-transitory computer-readable medium of claim wherein the process further comprises: determining an out of pocket cost to be paid by the user for the fulfillment of the prescription at the pharmacy; and further modifying the first data by including in the modified first data that is transmitted to the one of the plurality of third party pharmacy benefit managers an indication of the out of pocket cost.

“14. The non-transitory computer-readable medium of claim wherein the process further comprises: determining a reward to be provided to the user for the fulfillment of the prescription at the pharmacy; and causing the reward to be provided to the user.

“15. The non-transitory computer-readable medium of claim 14, wherein the process further comprises: determining that the reward to be provided to the user comprises a payment to be made to the user by the pharmacy; and wherein modifying the first data comprises adding to the first data an indication of the payment to be provided to the user by the pharmacy upon a fulfillment of the prescription.

“16. The non-transitory computer-readable medium of claim 15, wherein the process further comprises: retrieving, from a database, the one of the plurality of third party pharmacy benefit managers identified for the fulfillment of the prescription by the user prior to receiving the first data.

“17. The non-transitory computer-readable medium of claim 10, wherein the process further comprises: charging the out of pocket cost to a financial account associated with the user.”

For the URL and additional information on this patent, see: Greenblatt, Aaron. System for pre-adjudicating and modifying data packets in health claim processing system. U.S. Patent Number 11875415, filed March 31, 2023, and published online on January 16, 2024. Patent URL (for desktop use only): https://ppubs.uspto.gov/pubwebapp/external.html?q=(11875415)&db=USPAT&type=ids

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