HIT Perspectives: Breaking Through Barriers to Advancing Electronic Prior Authorization

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HIT Perspectives – June 2019


Breaking Through Barriers to Advancing Electronic Prior Authorization

Jocelyn Keegan Ken Kleinberg

By Jocelyn Keegan, Payer Practice Lead,
and Ken Kleinberg, Innovative Technologies Lead 


Dr Burnout

Physician offices spend 853 hours a year completing PAs (2017 AMA Survey)

Prior authorization (PA) is at the top of national interest and debate… at the nexus of decisions we are making as an industry and society regarding what care and therapy to provide, including the most advanced care, as well as how much it should cost and how much of it patients can afford.

While many wish PA would go away altogether, that’s probably not realistic in the short to midterm because payers see PA as an effective tool for utilization management. Electronic prior authorization (ePA) is reaching an inflection point where automation will likely take some of the sting out of the process. As more data flow, the opportunity may arise for payers to reevaluate their current PA requirements so as to reduce the number of treatments requiring it. For the purposes of this article, however, the focus will be on ways to move ePA forward.

As an industry, we have made progress advancing ePA. However, its adoption beyond the pharmacy benefit for retail drugs has been minimal. As conveyed in our recent industry report, in order to move ePA adoption levels to meaningful levels for specialty and complex therapies covered under both the pharmacy and medical benefits, numerous misconceptions and gaps must be addressed. Some key areas include:

  • Organizations should understand that ePA is a multitransactional process that has evolved with distinct processes and standards for therapies covered under the pharmacy and medical benefits. Many industry stakeholders – including regulators – have mistakenly held a monolithic view of ePA, impeding progress.
  • Payers will need to invest in streamlining and combining how pharmacy and medical claims are processed, as well as increasing the accuracy of PA flags and information. Providers and their EHR vendors will need to adopt more modern approaches to extract information from their systems to support ePA.
  • Stakeholders should understand that PAs may be reduced but will not be eliminated by value-based contracts or use of the real-time pharmacy benefit check (RTPBC). The RTPBC is a new transaction that provides real-time information about the cost of a prescription – and if PA is required – at the point of electronic prescribing. In conjunction with ePA, the RTPBC will help prescribers identify the lowest cost medications covered by a patient’s prescription drug benefit.
  • One of the main drivers of PA is the rising use of expensive and complex specialty medications. Although only 1% of prescriptions are for specialty drugs, they account for a third (rising to half) of pharmacy plan costs, with many requiring PA. Organizations should focus on addressing ePA for specialty meds, where the most immediate and real opportunities lie. Examples of opportunities include the National Council for Prescription Drug Programs’ recently established Specialty Work Group that is addressing the gaps that exist in specialty meds electronic prescribing (ePrescribing) and the HL7-based Da Vinci Project Coverage Requirements Discovery, which is a FHIR-based API that enables care delivery organizations and providers to query payers in real-time to find relevant guidance prior to care delivery to increase efficient delivery of care and corresponding payment.
  • Organizations should adopt the Point-of-Care Partners (POCP) ePA maturity model of increasingly sophisticated digital processes, information extraction/exchange and automated decision making to assist with utilization management success and moving in the direction of converged and value-based models.

To be sure, there is much more to the ePA story than we can cover in this article. Learn more with POCP’s newly released, in-depth report on ePA. It offers health care stakeholders an independent analysis of the market, realistic maturity models and technical frameworks, a profile of what vendors and service companies are currently doing in ePA, and actionable advice and predictions so they can arm themselves with the information needed to plan strategically and meet their goals. In particular, it analyzes the use of new and transformative Da Vinci Project use cases, supported by the Centers for Medicare and Medicaid Services, built around Fast Healthcare Interoperability Resources open application program interfaces.

The report leverages our unique perspective and relationships in the market with payers, providers and their vendors. POCP experts drew on their extensive experience with ePA, ePrescribing, medication management and transactions in support of value-based care, together with industry interviews, to craft this compelling report. It’s our most extensive research report to date, with 40+ diagrams and tables, profiles of 40+ vendors in the ePA arena, and 90+ references.

To learn more about ePA and POCP consulting services, visit the POCP website or contact Jocelyn Keegan. To learn more about the ePA report or purchase it, visit its download page or contact Ken Kleinberg.