Introducing Cloras in Healthcare Industry: The Ultimate Healthcare Integration Platform

By October 23, 2019 No Comments

Do you know Healthcare Integration is forecasted to grow 10%?

There is no dearth for illness and disease. With that being said, the healthcare industry is exponentially growing and an innumerable number of patients are visiting a doctor per day in the United States. Moreover, healthcare is a superset of a broad collection of industries ranging from drug manufacturers, distributors, pharmacies, health care insurance providers and pharmacy benefit managers. Considering that the healthcare transactions in the United States happen primarily through an insurance provider, integrating all the above-mentioned healthcare points would provide smooth hassle-free operation.

Applications healthcare integration used by related businesses would ultimately mitigate the struggles faced both by the people, aka, the end-users. With respect to the insurance providers and pharmacies, they can process medical and prescription transactions quicker than ever before, thereby catering to a larger number of people per day. And Cloras is there only to perform that, i.e. integrating business systems used by healthcare insurance providers and pharmacies.

Before looking into how integrating healthcare providers’ application with that of pharmacies can provide the above-mentioned benefits, let us now look into the healthcare industry scenario in the united states.

Healthcare Provider

Healthcare providerA health insurance provider network is a group of health care providers that have contracted with a health insurance carrier (via an HMO, EPO, or PPO) to provide care at a discount and accept the discounted price as payment in full.

A health plans’ network includes health care providers like primary care physicians, specialty physicians, labs, X-Ray facilities, home healthcare companies, hospice, medical equipment providers, infusion centers, chiropractors, podiatrists, and same-day surgery centers.

Health Maintenance Organization (HMO):

A Health Maintenance Organization (HMO) is a health plan that mandates a person subscribed to it, to contact medical services through a primary care physician or otherwise called a “gatekeeper”. A patient, in case of a health issue, has to consult the PCP initially, who will be redirecting the patient to any of the physicians in the state or city, that the plan covers. In case a patient accesses a physician out of the plan coverage or if any physician is accessed without PCP consultation, the payment has to go out of the individuals’ pocket.

Preferred Provider Organization (PPO):

A Preferred Provider Organization (PPO) is a health plan which if a person subscribes to, need not consult any Primary Care Physician (PCP) in case of a medical requirement. Though they will get maximum discounts and coverage if they consult a doctor under the plans’ coverage, they can even consult any physician outside the coverage of PPO, and still avail some amount of benefits. PPO provides for much more relaxed insurance guidelines compared to an HMO. 

Exclusive Provider Organization (EPO):

An Exclusive Provider Organization or EPO is a health insurance plan that is a hybrid of both HMO and PPO. As a subscriber of EPO, a person can avail the health plan benefits even though they consult a doctor without the referral of a PCP but will have to pay from their own pocket, in case they consult a physician or a hospital that are out of the plans’ coverage.

Pharmacy Benefit Manager

In the United States, a pharmacy benefit manager (PBM) is a third-party administrator of prescription drug programs for commercial health plans, self-insured employer plans, Medicare Part D plans, the Federal Employees Health Benefits Program, and state government employee plans. According to the American Pharmacists Association, “PBMs are primarily responsible for developing and maintaining the formulary, contracting with pharmacies, negotiating discounts and rebates with drug manufacturers, and processing and paying prescription drug claims. Pharmacy Benefit Managers (PBMs) reduce prescription drug costs and improve convenience and safety for consumers, employers, unions, and government programs.

Member Out-of-Pocket Maximum

Healthcare Industry is growing day by day with various changes from the federal Mandate, State Mandate and demand to create new products with cost-efficient and quality healthcare. Today, most of the Healthcare providers need to integrate their Medical with Rx claims from various Pharmacy Benefit Management and provide a consolidated Member Out of Pocket. 

In the United States, Out-of-Pocket maximum is the maximum amount of money that a person needs to take care of/spend from their own wallet before the insurance provider takes up the expenses. Since, all the healthcare expenses have to go through the health insurance provider, prior to process a medical and/or pharmacy claim, the healthcare provider or PBM has to check the member’s out-of-pocket maximum and based on the member’s balance the claim has to be processed.

Tracking Out-of-Pocket Maximum:

Whenever a patient goes to a pharmacy or any healthcare service provider such as physicians, labs, hospitals.., the claims will be billed based on member’s benefits and the out-of-pocket maximum. If the member didn’t meet their out-of-pocket then, the member will be billed for the services (based on their benefits). If the member met their out-of-pocket then, the pharmacy or healthcare insurance provider will pay for the services (based on their benefits). Without integrating the application of the healthcare insurance provider and pharmacy, all these processes of tracking medical out-of-pocket expenses become a tedious process.

CLORAS – The Cloud Healthcare Integration Platform that Synchronizes your Healthcare Applications:

In order to support this integration, you can leverage Cloras which will easily integrate both Medical and Rx accums and provide the accums for a member in real-time. Cloras will act like a Middleware application that will seamlessly pull the Medical and Rx accums from your source systems (or vendor system) through API and on a real-time basis, and it will give the Member Out of Pocket on a real-time basis. Integrating healthcare insurance providers and pharmacy benefit managers (PBM)s will eliminate members out of balance or excess keep both systems updated and synchronized.

This will help in improving your business and add more clients on your end. This also will help in easy integration with any Pharmacy benefits manager and compliance with HCR MOOP Mandate.

Advantage of Integration in Healthcare Industry using CLORAS:

Cloras can be used to integrate with any Pharmacy benefits manager through API or batch mode. Cloras can be easily configured to meet the state and/or federal mandate and provide real-time accumulation data that can be used in supporting customer service. Businesses can generate various reports/dashboards as part of the implementation from Cloras.

Now, if you are a pharmacy benefit manager, healthcare insurance provider, pharmacist or any other healthcare service provider, all you have to do is Request a free one-on-one demo at your convenient date and time with our integration expert who will take you through the above-discussed Integration process using CLORAS. You can also Contact Us by filling out a simple form stating your integration requirements.

Mohideen Kulam

Mohideen Kulam

Mohideen Kulam is a Programmer Analyst/Healthcare Business Systems Analyst working at DCKAP since the past 12 Years. He is an expert in handling Healthcare related projects and has spearheaded many vendor integrations. In particular, he handles intricacies pertaining to Enrollment, Claims, Portals, Billing and Reporting. During his leisure, he likes to read and explore new places.