What is the Largest Concern for Electronic Prior Authorization?

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Providers may soon be able to reduce the burden of prior authorizations on their practices and increase patient satisfaction at the same time.

Dealing with prior authorizations is a particular source of frustration in medical care, which means that the physicians must request for a prescription to be covered by the patient’s insurance plan. The biggest issue with this is that it interferes with a physician’s ability to provide effective patient care, as they must take the time to discuss with the pharmacy benefit managers and the payers. It also delays prescriptions for the patients.

Surescripts offers a service called CompletEPA connected to four pharmacy benefit managers who have contracted with health insurers to provide drug benefits. Surescripts is using a new electronic prior authorization (ePA) standard from the National Council for Prescription Drug Programs (NCPDP). In the year since it was adopted, they have received commitments from PBMs and physician EMR vendors to use the NCPDP standard.

DrFirst has an ePA that utilizes CoverMyMeds to give physicians the ability to submit requests electronically, through fax or online, using the NCPDP standard. CoverMyMeds then transfers the requests to the insurers in the form they require. However, for these ePA solutions to be effective, it is most important to integrate them into a practice’s EHR system. DrFirst is integrating other ePA services, including CompletEPA, and it will connect practices directly with some health plans and PBMs.

The estimated cost of prior authorization requests is $2,000 – $14,000 per physician per year. Enabling ePA will be cost effective and help to minimize interruptions in workflow. A list on Medical Economics explains the benefits of ePA:

  • Physicians are informed of prior authorization requirements before they prescribe a drug.
  • Only relevant prior authorization questions, depending on demographic and payer information, need to be filled out
  • EHR enables auto-population of patient data and ensures accuracy
  • Pharmacy benefit managers can communicate with physicians directly, in real-time, to ensure prior authorization is done
  • E-prescriptions that have already been approved do not need to undergo the prior authorization process

Electronic prior authorization addresses the efficiency issues doctors have been struggling with. However, there are also costs to consider, beginning with the cost of the ePA feature. To incorporate CompletEPA into the electronic health records, vendors are paying a monthly fee, and they are in turn charging physicians for the addition. This means physicians are tasked with choosing which features are most important for their system based on their budget. There is also the issue that not all insurers will accept electronic requests. Finding a universal solution is currently the largest concern for ePA.

Author: Apoorva Anupindi