POCP Blog

By Tony Schueth, CEO & Managing Partner

If you want to hit the healthcare jackpot in 2015, there’s one place you should place your chips:   electronic prior authorization (ePA) for medications.  The medication prior authorization process can now be dramatically streamlined via an ePrescribing transaction. The “endpoints” are now building or have built the infrastructure to take medication prior authorization from a days to weeks long endeavor to a fully electronic process that can be completed in 1-2 minutes within existing prescriber and pharmacy workflows.  There is no need to “pass GO” – the industry is at GO! 

Prior authorization is intended to be a cost-saving measure that helps ensure the safe and appropriate use of selected prescription drugs and medical procedures.   Current manual processes involving paper/phone/fax are very costly to administer for physicians, pharmacies and PBMs and, without automation, their administrative burdens will grow exponentially as volume and requirements for PA increase, particularly for specialty medications.

Paper-based ePA is a very time consuming process, and the cost of phone calls and faxes to gain approval is well understood by physicians and pharmacies. The current process, which takes 15 days on average, often results in prescription abandonment.

Electronic prior authorization enables providers to deliver more proactive care and keep patients healthy with efficient access to medications. In 2011, the National Council for Prescription Drug Plans (NCPDP) ePA Task Group learned that  ePA is #1 ePrescribing capability desired by doctors. Then last year, NCPDP approved an electronic data interchange (EDI) standard for ePA, after a successful pilot supported by industry leaders Allscripts, CVS Caremark, Navinet/CoverMyMeds and Surescripts.  

While prior authorization can be simplified through prescriber and PBM/payer portals, its full potential can be achieved with full integration into the ePrescribing workflow of EHRs. This ePA workflow is supported by the NCPDP SCRIPT standard described above, and is “prospective” because it is initiated by the prescriber and occurs before the electronic prescription is sent to the pharmacy.  When the prescriber is notified in real-time of a PA requirement, four things typically happen  when the NCPDP SCRIPT standard is integrated with the EHR: 

1. The prescriber answers PA specific questions based on the patient, plan and medication. Patient information may be pre-populated from the EHR.
2. The PA request is transmitted in real-time to be PBM and the prescription is pended.
3. The PBM returns an approval (or rejection) typically within 1-2 minutes.
4. The preapproved, clean ePrescription is routed to the pharmacy.

More advanced implementations will support appeal requests/responses and cancel requests/responses.  

EHR vendors are evaluating requirements for integrating ePA into their applications, and prioritizing ePA into their development roadmaps.  Considering that  Surescripts found that 28% of physicians surveyed would switch their EHR vendor for ePA, this is a good move for EHR vendors.

Companies to watch in the ePA space include CoverMyMeds and Surescripts.  CoverMyMeds introduced the industry’s first API for EHR vendors earlier this year and has a long track record of success with their ePA Portal.  Surescripts is rolling out CompletEPA,^™ their real-time ePA solution integrated into the EHR workflow. Services such as CoverMyMeds offer connectivity for all ePAs because even if the PBM or payer aren’t electronically enabled, electronically-initiated ePAs are delivered via fax. 

Looming overhead are regulatory requirements. A number of states, including MN, ND, MD and CO have mandated use of ePA beginning in 2015, and 10 other states have active regulatory activity which involves ePA. The coming regulatory mandates afford EHR vendors the opportunity to be ahead of the curve.  Rather than scrambling to meet multiple state regulatory deadlines at the last minute, vendors can begin development now to include ePA functionality while there is still breathing room to concentrate on workflow enhancements.With this approach, ePA will become as valuable to providers as ePrescribing.

Now is the time to spread the word about the new SCRIPT standard for ePA and its value.  To learn more, visit www.ncpdp.org.  If you are an EHR, health plan, PBM or pharmacy information network, now is the time to integrate ePA through implementation of the SCRIPT standard or through partnering with a company that offers a plug-and-play solution.

The time is right for standardized electronic prior authorization for medications. 

• Post Categories
• electronic prior authorization