Electronic prior auth offers real time response

Key Points

PRIOR AUTHORIZATION with its fax- and telephone-based process has remained one of the few lagging manual transactions, but its outmoded days are numbered.

Generally, electronic prior authorization (ePA) uses a smart decision tree or "conditional logic" according to Todd Workinger, manager, pharmacy programs for Horizon. Its ePA system can immediately generate an approval for a medication or request further review from clinicians if necessary.

SEEKING STANDARD SYSTEMS

Currently, the National Council for Prescription Drug Programs (NCPDP), a not-for-profit standards development organization, has yet to finalize a standard for ePA. Allison Orenstein, director of physician connectivity at CVS Caremark, is pushing to have its ePA fully functional this month and confirmed as an industry standard by NCPDP by August.

She blames the lack of standards for ePA as the primary barrier to implementation. NCPDP, which has been studying the process since 2004, cites lack of physician IT capabilities, insufficient return on investment and lack of organizational buy-in among the challenges of developing ePA.

NCPDP indicates that the one existing HIPAA-based standard related to prior authorization is insufficient to guide an electronic version, lacking a mechanism for providers to request and explain reasons for an override, for example. The council says its focus is on modifying existing standards rather than building new ones.

ePA enables physicians to submit an authorization request through hand-held devices or through a Web portal prior to pharmacy adjudication. Orenstein says that after the physician submits the ePA, the prescription for the approved medication will reach the filling pharmacy electronically for dispensing, which in turn, will notify the patient. Patients can pick up drug orders sooner with a fully electronic process.

Pending approvals would go under the scrutiny of clinicians, but Orenstein believes those requests would be addressed within 72 hours. Prescribers can check on the status of an outstanding PA request electronically as well.

Although the ePA process relies on a question and answer format, Orenstein says that it is necessary to build a flexible system that can integrate information with different payers and prescribers and make adjustments depending on the type of medication. She says that the CVS Caremark solution offers a framework for the flow of information during a PA review despite variations among payers.