How a Growing PBM Scaled Operations with Amphitheater

One PBM’s move off a fax portal and email to an integrated platform

The Challenge

Before Amphitheater, an independent PBM ran prior authorization the way much of the industry still does, through a detail-oriented workflow that relied on multiple manual handoffs. Special requirements, such as client sign-off for specific member groups, were coordinated through secure email threads, separate from the core workflow. This approach worked at lower routine volumes, but as PA volume grew, it became increasingly burdensome for their staff.

The PBM wanted to keep a human hand on execution; that part was never up for debate. Their clinical operations team was ready for a fully integrated system built to support and scale their existing workflow.

The Solution

Amphitheater offers a wide range of automation, from AI-assisted clinical review through fully automated authorization and notification. The PBM adopted the platform end-to-end, but chose to keep specific steps in their team’s hands rather than turn on every automation option available to them. Amphitheater is designed to support that choice: a configurable Fulfillment stage gives the PBM’s team a tracked, timed home for the execution steps they still run manually, inside the same connected platform as everything else, with the option to automate further whenever they’re ready.

In one rollout, the PBM went from fax-and-email to:

• A real queue, not an inbox. Every case visible, timed, and trackable 
• An auditable client sign-off process. Replacing email guesswork with a logged status and SLA
• Automatic, consistent notifications. Replacing hand-edited templates 
• Reporting that didn’t exist before. Management can finally see volume, turnaround, and SLA performance on demand

The Payoff and The Future

This wasn’t just an implementation to help their current process. This also a foundation. The PBM now sits on infrastructure that can grow with them.  More customization, more automation, and richer reporting are configuration choices for the future.  Epidaurus Health will continue to be a partner as we continue to help The PBM refine their Prior Authorization Process.

Comments on the results from a technician:

The results demonstrate what readiness for the next era of prior authorization can look like, with streamlined clinical operations driving reliable and consistent turnaround performance: Our company increased processing from 30 PAs a month to 30 PAs a day within a six-month period. Our systems and processes were established based on a low volume. As processing increased from 100 [Prior Authorizations] PAs a month to 100 PAs a week, our turnaround times started to be affected. Turnaround times remained within our quoted 24-48 hour period but more cases were hitting that upper limit than ever before. Our old processes required significant manual entry across multiple platforms.

In our first 3 weeks of using Epidaurus we received 668 cases. Our average turnaround time is 12 hours with many cases completed within 2 hours. Our workload has drastically reduced even with our steady increase in cases due to the reduction in manual data entry. The system is very user friendly and the support team has been phenomenal. The entire initiation process was incredibly well-supported and explained. The Epidaurus team ensured their system accommodated our specific group needs, even creating processes they had not implemented previously. I never felt as though this was a burden to them, they seemed to relish the challenge of creating a model that worked for us. After implementation, response times for minor bugs or questions we had could not have been better. The Epidaurus team has exceeded our expectations, allowing us to confidently take on more business while providing fast PA turnaround times with confident decisions. The only negative is not having worked with them sooner!

Comments on the new review experience from a pharmacist:

Epidaurus has helped us to create a streamline system with our prior authorizations.  Michael and his team have been very helpful as we switched to [Amphitheater].  They have helped us integrate all the details we needed into the system to make sure no detail was missed.  Epidaurus has saved our team time and effort in communication between our staff and prescribers.  

Our previous [workflow] was disorganized and involved many different systems.  It has been really helpful to use Epidaurus and have everything in one place.  It cuts down on time and effort during the prior authorization process, making us much more efficient.

With an average turnaround time of approximately 12 hours, many cases completed within two hours, and 97.6% SLA adherence during the first 30 days, Epidaurus’ newest client PBM is already building from a strong position.

As volumes grow and expectations rise, Epidaurus will continue working alongside the PBM’s team to refine the process, introduce further automation where it adds value, and sustain the fast turnaround times the PBM’s clients and members depend on.