New Standards Could Pave the Way for More Efficient Prior Authorization | PBMI 2024

Efforts are under way by health plans and technology providers, aided by new standards developed by the Centers for Medicare and Medicaid Services (CMS), to make the prior authorization (PA) of prescription drugs more seamless. Panelists during a session at the Pharmacy Benefit Management Institute’s Annual National Conference in Orlando discussed how technology is advancing to allow the prior authorization process to operate behind the scenes through electronic systems that are integrated with health plan information.

Eventually, the hope is that the systems set up to manage e-prescribing and prior authorization will be integrated with electronic medical records to allow providers to see which drugs require prior authorization at the point of prescribing and facilitate that process

“Instead of PA being something that engages members and providers, in this day and age where we have the access to data, this can be something behind the scenes that we would just code for in the benefit design,” said Kerri Tanner, Pharm.D., chief pharmacy officer, PayerAlly, a specialty pharmacy consulting firm, who moderated the session.

Before that goal of an integrated electronic prior authorization process can be realized, however, several challenges need to be addressed, including the adoption of new standards and the integration of systems. Even more critical, however, is convincing providers of the benefit such a system.

Tim Capstick

“There’s far too much faxing still happening in healthcare today,” Tim Capstick, regional vice president of health plans at SureScripts said. Surescripts processes about 23 billion transactions a year, but just 10% of those are e-prescribing transactions. The cost of implementing electronic systems is still a barrier for smaller health plans, PBMs and providers, he said.

“There’s some opportunity in the prior authorization space and in healthcare in general to tap into the clinical information exchange and automate that use,” Capstick said. “We as the stakeholders need to help some of the smaller organizations so that they can adopt the technology.”

The panelists at the session discussed how a prospective workflow for prior authorization can reduce the administrative workflow for providers and their staff and create a more efficient process for making sure that patients are able to get the appropriate medications.

Morgan Bojorquez

Humana was an early adopter of e-prescribing and prior authorization with the implementation of a retrospective system in 2014, which Morgan Bojorquez, associate vice president, pharmacy clinical integration, at Humana, said created many efficiencies and enabled a prior authorization workflow that had a turnaround time of 12 hours.

Humana has also initiated a prospective workflow from the electronic health system, but found that prescribers are more likely to adopt a retrospective system. “They wait for the pharmacist to tell them that the medication requires PA for the patient,” Bojorquez said.

Humana strives to implement solutions that support physicians at the point of prescribing, as well as pharmacists. One example, he mentioned was the process Humana implemented for approving prescriptions for GLP-1 therapies. “We have the ability at the point of sale, to evaluate the full medication profile of a patient when a claim comes in for a GLP-1. We don’t stop every claim,” he said.

For about 10% of claims Humana processes for a GLP-1 therapy, there is no evidence of diabetes. For those claims, Bojorquez said Humana leverages in real-time medical and pharmacy claims to look at historical medications to see if patients have diabetes. “We try to completely avoid the PA process by leveraging data and technology to facilitate that process.”

Bojorquez said this is the future of prior authorization. But to be implemented on a larger scale will mean bringing together data from multiple sources and unifying standards.

CMS is leading the way in bringing new standards for interoperability of data. Earlier this year, CMS introduced the Fast Healthcare Interoperability Resources (FHIR) standard for application programming interfaces to improve the electronic exchange of healthcare data and to streamline prior authorization processes.

These standards would allow for electronic prior authorization for medical services. Payers will be required to implement the prior authorization standards by Jan. 1, 2027, although some operational provisions should begin in January 2026. The standards apply across programs the CMS oversees, including Affordable Care Act plans, Medicaid and Medicare Advantage, and the Children’s Health Insurance Program.

At this point, the CMS rule doesn’t apply to prior authorization for prescriptions, but that could change in the future, according to an analysis by KFF.

One limiting factor, however, for widespread adoption of electronic prior authorization is the restriction of access to data for non-treatment use under the rules of the Health Insurance Portability and Accountable Act (HIPAA). “In many cases, there are handcuffs on what you can do that use patient data for up to and including a prior authorization. If those handcuffs were to come off and it’s done responsibly, we could really streamline and make the prior authorization process is very efficient,” Capstick said.

That’s where he said that qualified health information networks come in. These are network of organizations that work together to share data and ensure interoperability between the networks they represent. There are currently seven qualified health information networks, according to the Office of the National Coordinator for Health Information Technology (ONC).

“The intention is to remove the handcuffs, so to speak, of the information that is in an EMR, and open that up to not only treatment use cases but also non-treatment use cases, payment and operations,” Capstick said. “The networks start off in a treatment space, but but will need partners, health plans, payers, providers, etc, to look at use cases on the payment and operations side and build the workflows that are proper and everybody can agree to the terms of how information will be exchanged.”