Pharmacy Benefits Management

The Challenge

After many years of customizing and developing applications on the Salesforce platform, one Worker’s Compensation PBM faced several challenges with the administration and maintenance as a result of their customizations. The client had created core applications, including Quoting, Claims, and Sales Automation Management, with a significant amount custom code and data objects. The complexity created was very cumbersome. With all of the customization, the client experienced issues with the regularly scheduled Salesforce version updates and the growing amount of regression testing needed became burdensome for their existing staff. They also experienced primary business application failures, interruption to core business processes and often found themselves in a feverish scramble to get things repaired. Something had to change. The need for a robust and supportable solution with a native data model was apparent to both the technical and business leadership as the status quo was adversely impacting their business operations.

The History

Historically, this PBM focused on custom solutions developed by internal staff. This approach provided them with a sense of “control” to create the exact features and functionality they wanted, an opinion holding some validity due to the limited availability of configurable solutions (clicks not code) at that time. Today there are native solutions available on the Salesforce platform that provide a more robust framework. Custom code development is rarely necessary. The mindset of both the technical and business leadership evolved to understand that their business operations benefit from the robust, supportable, and scalable application framework provided by Salesforce Industries OmniStudio.

The Solution

The engagement was focused on implementing a solution to upgrade and streamline most of their current custom applications. It would have been unrealistic to attempt to address everything at once. The first course of action was to identify and prioritize their critical business processes with the most impact/benefit to the company. The following processes were highlighted with the greatest importance:

  • Quoting Process
  • Formulary Management Process
  • Claims Servicing Process
We will focus on the Quoting process here as it is most representative of the challenges they faced with custom code and data objects. The structure of their existing Quoting solution was solid, however it was built entirely upon custom code with core components that were difficult to update (e.g., pricing/rating tables, etc.). All of the core components were buried deep in the code base and required a skilled developer to implement and test modifications.

Our solution to streamline the Quoting process was based on using Salesforce’s OmniStudio tool set. This set of tools comprises a robust suite of Sales Administration applications representing comprehensive, technical components. We implemented the following components of OmniStudio as part of our solution:

  • OmniScript the User Interface (UI) component that provides the structure for the
    guided flow specific to end user navigation and interaction points.
  • Calculation Procedure this performs the calculations based on input variables and
    provides the final output values for the quote.
  • Calculation Matrices – these components provided the data that is referenced by the
    Calculation Procedure. These matrices can be versioned and controlled by start/end date ranges to govern which matrix/pricing is used and when.
  • DataRaptors – DataRaptors are a key component of OmniStudio as they provide a configurable mechanism for data access. Unlike complex custom code, these are created by configuration to extract, transform or load/write data.

Details of the quote calculations:

One component of the solution, separate from the Sales Automation application, is the Contract Lifecycle Management (CLM) framework. The functionality supported by this framework allows for quoting and contract templates to be customized using a rules-based approach that results in the production of a finalized quote package and any other supporting documents like the contract, etc. An additional contract related requirement was the capability to support eSignatures. After researching the solutions available in the market, the client selected DocuSign based on several factors to include DocuSign’s native integration with Salesforce Industries OmniStudio.

The Benefits

Salesforce’s solutions provide many benefits such as speed to delivery, configuration (clicks not code), robust and supportable framework, scalability, and ease of administration/maintenance. OmniStudio, along with the rest of the Salesforce Industries offerings seamlessly integrates with the Salesforce platform throughout all periodic releases (which happen 3X each year), minimizing the risk of critical applications/functionality failures following a Salesforce version upgrade.

Another benefit is the ability to embed the programmatic enforcement of business compliance and regulatory rules. Salesforce’s solutions can be configured to show/hide screens, sections of screens, fields, etc. based on certain conditions (selections made in the UI can drive a users’ available next actions). Decision support based on branching logic can also be implemented within an OmniScript to ensure that a business process and any non-standard use cases are covered. In addition, many of the components of OmniStudio are extensible and reusable which provides the benefit of configuring components once and reusing them to support various other processes and functions. This capability drives the reduction of Total Cost of Ownership (TCO) over time.

About Attentis Consulting

Attentis Consulting is a registered Salesforce and Silver level Vlocity (Salesforce Industries) partner. Attentis has completed many successful Salesforce Industries implementations and focuses primarily on the Healthcare vertical with deep industry knowledge in the Payor, Provider, PBM and Patient areas. We staff industry professionals with RN/NP, PharmD and CMS/Medicare experience to provide invaluable industry insight as well as fill key supporting roles on our projects.

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