Consider modernizing prior auth processes

Aug 01, 2011

There's a bill working its way through California that would require health plans to standardize their prior authorization paperwork.

I'm especially fond of home and office organizers, so all those fascinating little nooks caught my attention as well as my imagination. There were drawers reserved for heroin and arsenic, for example, which seemed like a dramatic contrast to the nearby stash of lavender and licorice.

Of course, everything in the shop was painstakingly labeled, often with the ingredient's Latin name. Today's pharmacist would certainly appreciate the efforts made to keep the products organized.

PRIOR AUTHORIZATION PAPERWORK

There's a bill working its way through California that would require health plans to standardize their prior authorization paperwork. The bill attempts to eliminate the varied authorization forms and enforce the adoption of a template to make such approvals simpler for physicians to handle.

Just considering the number of pharmaceuticals, it is extremely difficult to create an all-inclusive format. And the complexity is only increasing with the emergence of specialty drugs and tailored benefit plans.

For example, a typical prior authorization form for the asthma drug omalizumab might include 30 or 40 data fields that only the prescriber is authorized to fill in. The fields record detailed information, such as "Has the patient had at least three months of treatment on inhaled steroids?"

Collaborative groups, such as the American Medical Assn. and America's Health Insurance Plans, have made attempts at streamlining the prior authorization paper trail, but widespread standardization is lacking. Electronic medical records and e-prescribing initiatives will eventually drive a better process for prior authorization, so there's hope.

The Office of the National Coordinator (ONC) in Washington says it is not aware of a universal electronic format to distribute prior authorization forms. Nor is there a widely adopted, common industry transaction standard to support real-time electronic prior authorization. More practical work must be done before ONC could consider a policy recommendation.

Simpler administrative procedures are beneficial to patients and providers, but the ongoing burden will likely fall on health plans. Individually, plans will need to consider the business case for modernizing their prior authorization processes.

If a plan is going to incur the expense of a high-cost drug, it is in its own best interest to interact with the physician for the sake of good care and good financial management. A physician might have excellent expertise and experience in recommending drug therapies, but the plans have far more data to draw upon. Together, they build the comprehensive view.

While prior authorization is no one's favorite task, it is an essential component of healthcare that is long overdue for an upgrade.

Julie Miller is editor-in-chief of MANAGED HEALTHCARE EXECUTIVE. She can be reached at julie.miller@advanstar.com

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