Electronic Prior Authorization Being Brought into Pharmacists’ Workflow

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By Jocelyn Keegan, Senior Consultant

With recent legislative changes and maturity in the industry, pharmacists will soon be enabled to electronically initiate and handle pre-approval—or prior authorization (PA) — directly to payers, which will expedite the dispensing or administration of therapies. This is due to the work underway to expand the use of prospective electronic prior authorization (ePA) by the National Council for Prescription Drug Programs (NCPDP). ePA allows real-time — or near real-time — handling of a PA request. This minimizes or eliminates the delays, frustrations and potential patient safety problems inherent in the antiquated phone-fax-paper process.

Until recently, implementation was focused on ePA in the prescriber’s electronic prescribing (ePrescribing) workflows. Now attention is turning to how pharmacists can leverage the ePA transaction in workflows related to their various roles in the care continuum. We see this in the development of new use cases and legislation.

New use cases. Use cases continue to evolve to better include pharmacists and ePA. There is active work underway in an NCPDP workgroup to develop a use case for an ePA, based on the NCPDP standard, to be initiated by a clinical pharmacist in the post-acute care setting.

This makes sense for several reasons. Under current practice, the pharmacy has often been the only place where need for a PA is determined and follow-up is handled — usually through antiquated paper-fax-phone processes. These are outside their current electronic workflows, so it is logical to incorporate the standardized ePA into pharmacy system workflows. A second reason is that pharmacists increasingly are becoming an integral part of the patient’s care team across care settings, a concept that is expanding as providers move from fee-for-service models to value-based care. It allows the care team to make use of the clinical pharmacist’s knowledge about all aspects of the patient and related care. As a result, a pharmacist on a care team is often well-positioned to initiate a PA as well as answer questions that a payer may have.

Legislation. Legislation also is a driver for ePA as states are beginning to recognize the benefits of the transaction based on the NCPDP standard. Eleven have enacted laws mandating payer support for prescriber-initiated NCPDP formatted PA transactions. In a newly enacted law, Indiana is taking it a step further with requirements around ePA transactions initiated by pharmacists. Beginning on January 1, 2018, commercial health plans – including workers’ compensation – under the purview of the state’s insurance commission must accept and respond to NCPDP-formatted electronic prior authorization requests from a prescriber or from a dispensing pharmacist.

Of course, Indiana’s statute does NOT mandate the pharmacist use this approach or say other methods are possible nor prohibited. Nonetheless, it is likely to be another step to further promote wide-spread adoption of ePA. States watch each other. Once the ice has been broken with the respect to a particular regulatory approach, other states will follow suit.

All in all, there is a confluence of events and business needs that will continue to serve as drivers to ePA adoption by pharmacists. To learn more about the active discussion underway, contact me or join the conversation at the NCPDP Prior Authorization Workflow to Transactions Task Group.


Jocelyn Keegan

Jocelyn Keegan

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