SamaCare raises $17M to build out its prior authorization platform

Steven Loeb · May 21, 2024 · Short URL:

The company will be expanding into other areas standing in the way of patients getting needed care

While medication adherence, or getting people to fill their prescriptions, and then actually take their drugs, has been an issue for a very long time. However, not all adherence issues are the same: take specialty medications, which are for patients who have ailments such as cancer, degenerative eye disease, or a debilitating autoimmune disorder, the reasons they don't get on therapy are less along the lines of not being sure it's helping and more because of issues such as prior authorization, aka the paperwork that insurance companies require doctors and patients to fill out in order to approve the use of aid therapy. 

That's where SamaCare comes in: the company streamline the prior authorization process in order to help patients get access to the drugs they need.

"When a patient gets a diagnosis for a condition that requires one of these drugs, that is one of the worst episodes they've ever experienced in their life. They're being told they have cancer, they're being told they have debilitating rheumatological conditions or could potentially go blind," Syam Palakurthy, founder and CEO of SamaCare, said in an interview with VatorNews. 

"And so, it's less about, 'how do we convince patients to actually use the drug?' and a lot more of these administrative and financial blockers that prevent them from actually getting on therapy and staying on therapy is because these drugs are so expensive."

Now, SamaCare wants to branch out to other areas and barriers beyond prior authorization, and to do that it has announced an oversubscribed $17 million Series B investment round on Tuesday led by new investor Questa Capital, along with existing investors Vive Collective and South Park Commons.

This is the company's first funding since its $12 million round in 2022, and it brings its total raised to around $35 million.

Founded in 2018, SamaCare offer a platform that medical providers use for free to streamline the submission, the tracking, and the management of prior authorizations to insurance companies.

Medical practices use the SamaCare platform to submit, and automatically track, the status of each submitted prior authorization, so their staff doesn't need to manually check if a patient is approved for a therapy, or if an insurance company needs more information. The practices also get regular prior authorization reporting, with metrics such as average resolution times, which can help practices avoid having to reschedule or delay starting treatment. 

While the platform is free for medical practices, the company makes its money from pharmaceutical manufacturers who pay for add premium features, including region specific data, and the ability to enroll patients into other services offered by the pharmaceutical manufacturer, including nurse support, adherence programs, and financial assistance.

Benefits for patients, providers, and pharma companies 

For the patient, the benefit they get from SamaCare is fairly obvious: they get to take the drug that they've been prescribed by their doctor. The provider, meanwhile, gets to cut down on the administrative staff necessary to manage these administrative burdens that are getting in the way of actually delivering treatment, Palakurthy explained. 

"My dad was an electrophysiologist: when he started practice, he had one administrative support staff for every doctor at his six doctor private practice. When he left, it was 16 administrative support professionals for every doctor that was there. So, it's more and more challenging every year to get through all these administrative burdens," he said.

"The ROI for the practices really comes down to, they have so many people that they need to hire, it's hard to hire new people, someone leaves and all of a sudden there's a huge loss of knowledge, it takes six months to train someone new in these complex processes. So, we're making it much easier for them to get through this process to make sure that it's being done correctly."

SamaCare did a structured case study, where it found that providers were spending about 43% less time on prior authorization, as well as a reduction in administrative denials.

Another ROI for providers is financial: because the drugs that SamaCare focuses on are being infused or injected in the office, they're going through what's called medical benefit, meaning that the doctor is actually buying the drug indirectly from the pharmaceutical company and then getting reimbursed by the insurance company. So, if they inject a drug into a patient's body and the insurance company comes back and says they didn't have a prior authorization, that's a huge out of pocket cost for the provider. By allowing them to check the prior authorization before, it saves that potential cost. 

On the pharmaceutical side, the ROI comes down to the fact that they've spent money to get the drug developed, and then on marketing and sales, but then patient who is prescribed doesn't end up taking it, which is a huge loss for them.

"They're essentially losing that patient at the one yard line; they've done all this work and the patient isn't actually getting across the finish line because of administrative issues like prior authorization, financial blockers that prevent them getting out therapy, or other things that slow down the process that make it just a little bit less likely for them to actually get on therapy," Palakurthy explained.

"So, for the pharmaceutical companies, it's really about making sure that we can solve that last mile challenge. They’ve convinced the market, they’ve convinced the patient, the doctor that this is the right therapy for them, how do we help them make sure that that patient actually gets on therapy and stays on therapy?"

By reducing the overall turnaround time for prior authorization, SamaCare has been able to reduce the amount of patient leakage, meaning those who don't get on therapy, by about 50%. The company also ran another case study that showed that it could decrease the number of administrative denials by about 12%, all of which results in an ROI of anywhere from 5x to 15x.

Growing beyond prior authorization

Since its last funding raise, the company has continued to hone in on its existing strategy, while focusing on growing to more medical providers and practices, and even expanding the number of specialties, Palakurthy said. 

"Two years ago we were much more constrained but we've since expanded. So, we started in retina within ophthalmology, and we've now expanded into oncology, rheumatology, neurology, and ambulatory infusion centers. So, we continue to grow the number of providers using our system, and the number of pharmaceutical manufacturers we partner with," he explained. 

More recently, though, the company has started to expand into new areas beyond prior authorization, which also stand in the way of patients getting their needed therapy. That includes benefit verification, or understanding what the patient's coverage actually covers, as well as helping with enrolling patients into pharmaceutical support services.

Over the next year and half, SamaCare is going to be taking on more of those workflows, building that Script-to-Therapy operating system to support all those workflows with the plan that, by the end of next year, the company will be in a place where other parties, such as third party technology companies and other industry stakeholders, can actually build on top of its platform based on the wide network of providers that it has built.

"As we think about this fund raise, and why we raised it now and what we're planning to do with it, we've started to really broaden out beyond just prior authorization to other aspects of what we call the Script-to-Therapy journey. So, prior authorizations is just one obstacle along the way after the prescription has been written, to get the patient on therapy, and to get them staying on therapy," Palakurthy said.

The funding will also go toward building out the platform to make it easier for new practices to adopt SamaCare, including building out more artificial intelligence, all with the goal of building towards a world where every patient is able to get on the right treatment, based on the clinical nature of their condition and the judgment of the doctor, while not being impacted by what Palakurthy calls "these dumb administrative or financial blockers."

"We want to make it so, not just prior authorization, but all of these other administrative and financial obstacles in the way are as simple to get past as a credit card swipe. Right now we're so far from that but the way that we get towards that vision is by continuing to grow our network of medical providers, so getting the broadest network possible. but also making it really really easy," he said.

"We're going to connect these different pieces into a single workflow, from script to therapy, such that it is actually just as simple as the doctor writing a prescription, and rather than there being different steps that someone needs to go through, which all need to all be done in series, and all done manually, having that be just a single workflow where they can click a series of buttons and have it the patient is ready to go and ready to actually get that therapy literally the day that the patient and the doctor decide that's the right treatment for them."

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