Systems and methods for increasing prior authorization success rate for specialty drugs

A method comprising:

• monitoring acceptances and denials of claims due to prior authorization requests for a plurality of drugs associated with a manufacturer by a computing device, wherein each claim is associated with a provider of a plurality of providers;
• for each provider of the plurality of providers and each drug of the plurality of drugs, computing an acceptance rate for the claims for the drug and the provider by the computing device;
• determining that a computed acceptance rate for a first drug of the plurality drugs and a first provider of the plurality of providers falls below a threshold by the computing device;
• and
• in response to the determination, initiating training for the first provider on preparing prior authorization requests for the first drug by the computing device.

A system comprising:

• at least one computing device;
• and
• a memory storing instructions that when executed by the at least one computing device cause the at least one computing device to:
• receive a claim from a provider, wherein the claim is for a drug produced by a manufacturer;
• transmit the claim to a claim processing system;
• receive a claim denial response from the claim processing system;
• update one or more metrics for the provider and the drug based on the claim denial response;
• determine whether the one or more metrics fall below a threshold for the manufacturer and the drug;
• and
• if it is determined that the one or more metrics fall below the threshold, initiate training for the provider.