Electronic prior authorization (ePA) is gaining traction and attention after a lull in progress and focus. The need for ePA is easy to understand. ePA is essential in reducing time to therapy, friction and costs by aligning payer and provider goals. The “how” is catching up in a big way. Now new technologies, evolving standards, government regulations and ePA’s role as a critical tool for value-based care have created a perfect storm. The industry has brought ePA to an inflection point, and several leading payers, providers, vendors and standards groups are driving to advance ePA by making automated prior authorization (PA) the norm rather than the exception.
A way to conceptualize this progress is shown in the figure below. There are three phases in the evolution of ePA. The industry is rapidly transitioning from phase 1.0 and heading to phase 2.0.
ePA 1.0. This first phase is focused on ePA for medications covered under a patient’s pharmacy benefit. Substantial progress has been made and is ongoing. Take, for example, the latest version of the SCRIPT standard by the National Council for Prescription Drug Programs (NCPDP). NCPDP SCRIPT version 20170701 contains ePA transactions that are more robust than those contained in the current ePA standard (ASC X12 278) and offer the ability for performing ePAs in real time.
Adoption of the NDPDP standard will be reinforced with the newly proposed rule from the Centers for Medicare and Medicaid Services (CMS), which would require use of ePA transactions contained in NCPDP SCRIPT 20170701 for drugs prescribed under Medicare Part D instead of the ASC X12 278. The proposed implementation date is January 1, 2021.
Another CMS rule will support and accelerate use of the real-time pharmacy benefit check (RTPBC). The rule requires adoption of a “Real-Time Benefit Tool” by Medicare Part D plans beginning January 1, 2021. NCPDP has developed a draft standard for this transaction, which was approved to move forward at the August 2019 workgroup meeting.
With the RTPBC, both prescriber and patient can have up-to-date information on the out-of-pocket costs of a drug that is being prescribed as part of the electronic prescribing (ePrescribing) process at the point of care through the electronic health record (EHR). When used with ePA, the two transactions deliver more accurate information about coverage and costs of drugs at the point of prescribing and allow physicians to help their patients begin therapy faster. The newly proposed ePA transactions would enable the prescriber to submit the required information in real time and indicate in the RTPBC whether PA is needed. This will help the physician obtain faster approval and improve speed to therapy.
Improving the quality of the signal for PA through RTPBC will bolster the accuracy and utility of ePA as part of the prescribing process, such as support from industry groups such as the American Medical Association, which continues to support adoption of ePA as a way to reduce physician burden.
Taking ePA to Level 2.0. ePA 2.0 involves automating PAs for drugs covered under a patient’s medical benefit (mPA), such as drugs covered under Medicare Part B. Reducing provider burden is an increasing focus from the Department of Health and Human Services, including notices of proposed rulemaking that would increase the ability for payers to share coverage decisions as members change plans and make continued investments in emerging technologies that can expose coverage rules to providers in their work flow.
Currently, most PAs for those medications are processed manually through antiquated phone, fax and paper processes. There are several drivers propelling ePA to the next level. These are being addressed by various stakeholder initiatives. For example:
At the same time, prescribing specialty medications generally is a manual process, leading to provider frustration and reduced speed to therapy. Automating and standardizing specialty pharmacy transactions will be the focus of a new workgroup that has been formed by NCPDP. The goal is to bring greater focus and coordination in how NCPDP standards are used for the electronic exchange of data in specialty pharmacy, including addressing gaps that exist in ePrescribing for specialty medications. This will complement and support ongoing NCPDP efforts to automate various aspects of specialty pharmacy, including the patient enrollment process. In addition, NCPDP and HL7 are working together to use Fast Health Interoperability Resources (FHIR) to extract the necessary clinical data required for enrollment from the native EHR.
To be sure, this new tranche of work is early, but stakeholders are ramping up to enable their platforms for API access so ePA can move to the next level.
Moving to ePA 3.0. ePA 3.0 will automate PA for devices, procedures and services covered under the medical benefit. Electronic medical prior authorization is in its early phases, but real work is under way with significant interest and attendance at Da Vinci working sessions and Connectathon activities. Many challenges must be addressed to bring ePA to version 3.0. For example:
Need more information? POCP is here to help. Drop us a line (email@example.com and firstname.lastname@example.org). Also, don’t overlook the wealth of information in our new ePA report. This extensive document — with 40+ diagrams and tables and 90+ references — offers health care stakeholders an independent analysis of the market, realistic maturity models and a profile of what vendors and service companies are currently doing pertaining to ePA so they can arm themselves with the information needed to plan strategically and meet their goals. Set up a one-on-one meeting to discuss how this report may help your organization by calling us at 877-312-7627, option 4, or dropping us an email at email@example.com.