Insurers, CMS Seek to Ease Prior Authorizations

Heads up, clinicians: health plans and the federal government are each rolling out their own new programs to simplify prior authorization (PA), even as the industry coins a new contradiction in terms — “retrospective prior authorization.”
“Believe it or not, plans don’t like prior authorization either,” Kate Berry, senior vice president for clinical affairs and strategic partnerships at America’s Health Insurance Plans (AHIP), said here at the annual meeting of the Office of the National Coordinator for Health Information Technology. “We know there are lots of opportunities for improvement.”

AHIP is rolling out a project known as Fast Path that it hopes will smooth the automated process for PA for drugs and for medical procedures and devices. The project is expected to begin in 60-90 days and run for about six months. Two vendors — SureScripts on the pharmacy side and Availity on the procedure and device side — are partnering with AHIP on the system; the seven plans participating provide health insurance to about 60 million Americans, Berry said.

Kate Berry, America’s Health Insurance Plans (Photo by joyce Frieden)

On the pharmacy side, doctors and other prescribers should be able to use the Fast Path portal to access the patient’s pharmacy benefits and know whether the specific medication requires prior authorization, AHIP says on its website. If the medication does require PA, the doctor can see whether there are alternative medications that don’t, or, if they prefer, they can immediately submit a PA request for the original drug. The portal also will let prescribers know the patient’s estimated out-of-pocket cost for the drug.
On the procedure and device side, doctors will know immediately whether the procedure requires prior authorization based on the patient’s specific health insurance coverage, and will be able to submit the necessary information and get a response from the plan through the portal.
AHIP is hoping Fast Path will “enable information exchange — bidirectional, supported, and streamlined — to reduce those phone calls and faxes,” said Berry.

A Good First Step
Rob Tennant, director of health IT policy at the Medical Group Management Association, a trade group here for physician practices, said in a phone interview that Fast Path was a good first step, especially the pharmacy element of the program. “I hope that we’ll see its use skyrocket; it’s better patient care and patients will be happy and potentially their out-of-pocket expenses will go down,” he said.
The part that addresses procedures and devices, on the other hand, is not as comprehensive a solution, both because it only involves a small group of health plans, and because it requires physicians to get out of the electronic health record and sign on to a separate web portal, Tennant continued.
“The benefit of the approach is that you eliminate a little hassle, because right now each plan has its own proprietary web portal with different sign-ons and different passwords,” he said. “This way, it would be standardized at least for these health plans, but it’s not a long-term solution to prior authorization.”
On the public side of the issue, the Centers for Medicare & Medicaid Services (CMS) has surveyed thousands of stakeholders — including patients, clinicians, and healthcare facilities — through listening sessions, on-site visits, and interviews, to find out their concerns with PA, said Alex Mugge, deputy chief health informatics officer at CMS. “Whatever policies we move forward with, we’re really trying to make sure we do it with a wide range of perspectives,” she said. “We got thousands of comments on the challenges with PA.”

To help clinicians figure out whether a drug or procedure needs PA, CMS is developing a Documentation Requirement Lookup Service (DRLS), Mugge explained. The service “will tell the provider at the point of care, ‘Does this patient have any PA requirements?’ And if the answer is ‘yes,’ it will say what they are. This is not PA itself, but what it does is eliminate the step of digging through websites” to find the answer.

Alex Mugge, Centers for Medicare & Medicaid Services (Photo by Joyce Frieden)

“CMS is aware that electronic solutions are not only the ones needed to address PA,” she added. “They will, however, improve efficiency and streamline parts of it, but non-electronic solutions also need to be put in place.”
Tennant, whose organization is part of a CMS workgroup that’s developing the program, said the DRLS “shows tremendous promise, with the caveat that this not be a Medicare-specific program. There can’t be one-off solutions.” Currently, the DRLS is only aimed at a small group of durable medical equipment, including CPAP machines and oxygen, with the possibility of expanding to other devices if it is successful, he noted.
“We are cautiously optimistic that this solution will be a universal one,” he added, referring to the idea of including commercial insurers and not just public plans like Medicare. “If it is, I think it could truly automate a portion of the prior authorization conundrum.”

Benefits of Centralization
Much work remains to be done to get more providers submitting PA requests electronically, noted Miranda Gill, MSN, RN, senior director for provider services and operations at CoverMyMeds, a company that develops websites for pharmacy prior authorizations. “When you look at PA volume in total, only about 46% of PA requests are submitted electronically. That leaves 53% done ‘old school’ — manually, by fax, or phone. That shows that technology helps but doesn’t automatically solve the problem.”
Technology has come a long way, however, she added. As an oncology nurse, “the first PA I ever did took me about 50 minutes on the phone,” she said. “Fast forward a few years, and submitting electronically took me about 20 minutes. That’s a pretty significant difference.”
Turnaround time has increased by about 13 days as more providers have gone from “retrospective” pharmacy PA — prior authorization initiated at the pharmacy counter — to PA that’s done prospectively, before the patient leaves the doctor’s office. “We would like to keep moving in the prospective direction,” Gill said.
“I’d be remiss not to mention one other trend we’re seeing from the prescription medicine PA process: the idea of centralized PA teams,” she said. “That shouldn’t come as a surprise to any of us that practice in healthcare; we’ve centralized a lot of things with pretty great outcomes.”
One study at the University of California Davis found that centralized pharmacy PA teams have a 10% greater submission rate, “indicating improvement in the quality of the PA and in efficiencies,” said Gill. Centralized PA also cut the time between PA initiation and PA submission by about 22% and decreased turnaround time by about seven days.
https://www.medpagetoday.com/practicemanagement/reimbursement/84587