Prior Authorization Reform Strategies

Prior authorization reform strategies allows payers to limit unnecessary spending on high-cost prescription drugs, but leading provider experts suggest that payers could do more to boost the efficiency of prior authorization procedures for clinically valid prescription requests.

A provider survey conducted by the American Medical Association (AMA) found that 90 percent of providers reported treatment delays because of prior authorization wait times and that providers spend an average of 16 hours per week completing drug access requests. Payers can improve the efficiency of prior authorization procedures through automated technology and implementing actionable recommendations from providers.

Prior Authorization Reform Technology

A survey conducted by SureScripts and published by AHIP found that a third of providers’ prior authorization orders are delayed by two days. The report suggested that prior authorization delays can occur less frequently when the process leverages automated technologies.

A software solution automatically updates forms as payers and providers communicate during the approval process, instead of requiring a provider to file additional prior authorization forms. In real-time, both the provider and payer simply update patient and benefit information in a patient’s EHR.

Benefits of this strategy include:

  • EHR integration
  • Accelerated response times for prior authorizations
  • Improvements in patient satisfaction
  • Improvements in patient care
  • Help payers improve gaps in care
  • Get beneficiaries necessary medications in minutes instead of days

Commercial Payers React

Select commercial payers have already announced adjustments to their prior authorization policies after soliciting provider feedback and identifying flaws in previous policies.

  • BCBS of Tennessee partnered with a pharmacy benefit manager to waive prior authorization requirements on specialty medications for patients during inpatient stay, in an emergency room, or in an observation room setting.
  • Humana has updated its online prior authorization toolto allow providers to submit more prior authorization documents to increase the speed of approvals. The tool also allows for immediate response times from Humana employees and lets a provider track a prior authorization process.
  • Aetna has waived prior authorization requirements for buprenorphine medications that treat opioid-abuse conditions

Payers that leverage provider suggestions and innovative technologies can reduce patient safety risks and ensure beneficiaries populations receive needed medications in a timely and efficient manner.