Electronic prior authorization eases burden

April 27, 2015

Using an electronic prior authorization program can save money and time for patients, providers and pharmacists.

Although important, obtaining prior authorization manually is a burdensome and frustrating administrative task that wastes money and time for patients, providers, and pharmacists.  The impact on pharmacists is highlighted by data showing that obtaining prior authorization cost $11,440.00 per pharmacist per year, and requires on average four hours per week to implement manually.

Using an electronic prior authorization program can reduce this burden, according to Ajit A. Dhavle, PharmD, MBA, vice president, Clinical Quality, Surescripts, Arlington, Virginia. “With a truly automated and fully integrated electronic process, pharmacists no longer need to spend time going back to providers for prior authorization requests and patients can quickly and easily retrieve their needed medications.”

Speaking at the Academy of Managed Care Pharmacy (AMCP) meeting in a session entitled Electronic Prior Authorization: Impact on Care Delivery, Dhavle summarized the current status of electronic prior authorization programs and described the National Council for Prescription Drug Programs (NCPDP) SCRIPT standard for electronic prior authorization and how it works.

Officially approved in July 2013, the NCPDP standard for electronic prior authorization transactions established a new standard that enabled options for electronic prior authorization workflow. The new best practice that emerged from this included leveraging eligibility and formulary data to notify providers of medication prior authorization needs before e-prescribing, and sending specific prior authorization questions to the electronic health record based on the patient, plan, and medication, without the need for forms. In addition, completing the prior authorization review is done in real-time with pharmacy benefit management (PBM) before sending e-prescription, and preapproved e-prescriptions are routed to pharmacy with no block on prior authorization.

“By implementing an electronic prior authorization solution, physicians and their staff can connect directly with their patients’ health plans to complete the prior authorization process without enduring the pain of using outdated and slow phone, fax, and portal systems,” said Dhavle.

To illustrate implementation of an electronic prior authorization program, Gulzar Virk, MBA, product manager, Physician Connectivity for CVS Health, spoke on lessons learned from a pilot program launched in May 2012 at CVS/Caremark. The pilot program found that about 11% of the total prior authorizations done through Caremark were done via electronic prior authorization at the end of 2014. About 17,000 unique national provider identifiers (NPIs) were requesting electronic prior authorization, and the top drug classes in which electronic prior authorization was used were sedative hypnotics, amphetamine, proton pump inhibitors, testosterone/Cialis, and methylphendiates.

According to Virk, lessons learned from the pilot project included a faster turnaround time using electronic prior authorization and that duplicate scenarios were detected at the front end of the process. He said, however, that the portal was not seen as a long-term solution and that it is much better if electronic prior authorization is part of the e-prescribing workflow.

He ended his talk by saying that more experience is needed to understand how electronic prior authorization will work in practice and how it will affect pharmacy workflow.