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But there are plenty of holdouts. Half of submissions are still done by phone or fax.
Most providers absolutely dread prior authorization. It adds to administrative work and may seem to stand in the way of good patient care. But for payers, “prior auth” is among the sturdiest, sharpest tools in the managed care toolkit because it gives them a way to control costs and steer physicians toward cost-
Could electronic prior authorization (ePA) bring the two sides together?
“Prior authorization has not changed much in the last five years, but we have seen a shift in the method in which prior authorization requests are submitted,” says Caitlin Graham, vice president of Core Network, a division of CoverMyMeds, a healthcare technology company in Columbus, Ohio, owned by McKesson Corporation. Traditionally, the prior authorization process has been cumbersome, with providers and health plans exchanging phone calls and faxes, says Graham. It is a time-intensive process (Graham puts it rather mildly) that places a burden on pharmacists, providers, health plans and, most critically, the patient who is waiting. As ePA software becomes more accessible to providers, the hassle and wait time for prescriptions may be declining — assuming that providers are ready and willing to use the new technologies.
The COVID-19 pandemic caused many payers to suspend prior authorizations of diagnostic tests and services related to the virus. The disease has reinforced the need to minimize points of friction in the prior authorization process and take the patient out of the middle, says David Lassen, Pharm.D., chief clinical officer at Prime Therapeutics, a PBM headquartered in the suburban Twin Cities and owned by Blue Cross Blue Shield plans. “COVID-19 will likely have a transformative impact on the future as telehealth, and digital automation and tools continue to evolve to meet the rapid demand for greater efficiency and effectiveness in the process,” Lassen says.
Many large health plans have temporarily changed their policies, but the need for continued change and ePA adoption reaches beyond the current pandemic. The ePA software typically integrates directly into electronic health records (EHRs) to provide a near real-time approval for many prescription drugs. Some software providers offer portals and additional software integrations that work alongside EHR systems. As of April 2020, 14 states require ePAs and 16 states allow it. The remaining states have pending ePA legislation, according to Surescripts, an electronics prescription company.
“Just as COVID-19 has impacted nearly every aspect of healthcare, we have seen prior authorization requests drop at the same rate as overall prescriptions in the past few months,” Graham says. “We anticipate that prior authorization volume will return to expected levels as states continue to lift
stay-at-home orders and as people begin to visit their healthcare providers for acute care.”
A domino effect
As more software is developed to make prior authorization less of an administrative burden, providers still struggle with the increased work that goes into the process. The result can be congested workflows that may, ultimately, result in poorer patient care, says Ross Moore, MBA, general manager for revenue cycle at Olive, a healthcare artificial intelligence company in Columbus, Ohio.
At a large health system, it’s not uncommon to have a team of more than 50 people responsible for managing the prior authorization process, notes Moore. Even then, backlogs occur and have a domino effect that may delay patient care, hinder quality and reduce patient satisfaction, he says.
Physicians are not fans of prior authorization. In a 2019 survey of 1,000 practicing physicians conducted by the American Medical Association, more than 90% of respondents said prior authorization had a negative clinical impact and 28% said it led to a serious adverse event, such as death, hospitalization, disability or permanent bodily damage.
PBMs are increasing the number of drugs they are excluding from their national formularies — formularies that the PBMs’ clients don’t necessarily follow but do set a standard. Exclusions make prescribing difficult when providers aren’t able to get real-time prior authorization results, Lassen says. Often, patients are stuck with dealing with the prior authorization process and finding out which drugs are both covered and affordable. “Practitioners don’t have sufficient information available to them at the time of prescribing or point of care,” observes Lassen. They should, he says, be able to identify a drug’s formulary status, utilization management criteria, cost and alternative covered therapies. Because of that lack of information, patients typically find out at the pharmacy that the drug is not covered or requires a prior authorization. “Unfortunately, that puts the patient in the middle of the situation and needing to go back to the practitioner to seek a prior authorization request,” says Lassen.
Struggles with ePA use
Although nearly all pharmacies, payers and EHRs have access to ePA in one form or another, half of prior authorizations are still submitted via telephone or fax, according to 2018 payer data collected by CoverMyMeds.
“Although the industry has moved readily to ePAs, most prior authorizations are still not fully automated, but this is the goal,” Lassen says. “With the increased use of prior authorizations for specialty and high-cost medications, the volume of work has potentially become harder.”
One reason providers avoid starting prior authorization requests at the point of prescribing is because they don’t trust the plan formulary information supplied in their EHRs, Graham says. According to CoverMyMeds’ 2020 Medication Access Report, 60% of practitioners report that they only sometimes trust the insurance data available in the EHR and 19% reported they rarely or never trust this information.
Another issue that providers face in increasing ePA adoption is the multiple platforms within a healthcare setting and their interoperability. “As many software and EHR integrations take place, it can be harder for practitioners to work on multiple platforms unless there is full integration into the workflow,” notes Lassen.
Graham says CoverMyMeds works directly with system vendors to develop integrations, making access to its ePA software easier.
Streamlining the most common prior authorizations could lessen the technology and administrative burden. According to Moore at Olive, part of the service that his company provides is an upfront determination if prior authorization is required. The company then helps facilitate authorization requests, frequently checks their status and manages prior authorization denials by automatically making appeals for procedures that have already been pre-authorized but were denied. Moore says that making prior authorization systems more efficient helps to improve the overall satisfaction of patients.
Earlier this year, America’s Health Insurance Plans (AHIP), the trade association for the health insurance industry, launched the Fast Prior Authorization Technology Highway (Fast PATH) program to assist providers in adopting ePA. Fast PATH utilizes the technology of Surescripts, owned by CVS Health, Express Scripts, the National Association of Chain Drug Stores and the National Community Pharmacists Association. As AHIP pitched it in a press release, when medications are ordered through the EHR, Fast PATH gives prescribers immediate access to patients’ pharmacy benefits so they know whether the prior authorization is required and have information about alternatives. And if the doctor prescribes a medication that does require prior authorization, he or she can immediately submit the approval request through the EHR.
Lassen says his company is also jumping on the ePA bandwagon and investing in strategies and tools that will serve up information at the point of care, including real-time benefit check, alternative drugs, cost comparison and the ability to auto- approve prior authorizations. “Our objective is to limit any friction to our providers and members and ensure people get the medicine they need to live healthy lives,” Lassen says.
Moore says one of the obstacles to a more streamlined approach to prior authorizations is the lack of uniformity. “There must be greater collaboration between payers and providers to set universal guidelines on requirements, starting with the high-volume, low-complexity procedure types that consume the greatest administrative cost across the healthcare continuum,” says Moore.
Donna Marbury is a freelance writer in Columbus, Ohio.