Simplify Prior Authorization

A multi-stakeholder initiative led by Connex Health Consulting.

About

The goal of this initiative is to create an industry solution to the challenges of prior authorization (PA) programs*.

This microsite has been developed to provide information on the Simplify Prior Authorization initiative to all stakeholders in the PA process and those with an interest in PA.

*Sometimes called special authorization programs.

The White Paper on Prior Authorization

Summary of what researchers found:

  • 1Stakeholders* subject to the process would benefit from greater consistency in the workflow process between payers.
  • 2More transparency and consistency in claim forms would improve the PA process.
  • 3Stakeholders would benefit from changes to the current paper-based claims process to reduce the administrative burden.
  • 4There is an opportunity to improve the consistency of the review and appeals process between payers.
  • 5Patients on PA drugs would benefit from industry grandfathering standards to prevent loss of coverage on transfer of carriers.
  • 6Payer metrics and stakeholder evaluations would identify opportunities to improve the PA workflow process.
Office Discussion

*Stakeholders include physicians, pharmacists, patient navigators, benefit advisors and plan sponsors/employers.

Office Presentation

Researchers Recommendations:

  • 1Create a web portal for all stakeholders with:
    • /On-line electronic claims process for PA claims (ePA)
    • /A repository of clinical evidence for payers
    • /Lists of PA drugs by payer
    • /Claim forms for PA drugs.
  • 2Improve transparency and create standardization in the workflow process.
  • 3Provide clear avenues within payers for appeal.
  • 4Develop industry grandfathering standards for PA.
  • 5Identify common metrics and reporting for payers as well as evaluations for physicians, patients and patient navigators.
  • 6Management by an independent agency.

The Plan to Simplify Prior Authorization

It isn’t easy to create industry-level change, especially when there many stakeholders involved, so we’re tackling it in a multi-phased process with the participation of numerous experts:

1

The white paper report on Private Payer Prior Authorization.

2

The Steering Committee and working groups will respond to the recommendations of the white paper.

3

The first pilots will go live and preparation will be finalized for full market launch.

Want to know more?

View our infographic for how we are creating change in prior authorization practices.

Podcasts

Featuring a conversation with Dr.Imtiaz Khan, Rheumatologist, practicing in Mississauga and Chair of the Ontario Rheumatologists Association Private Payers Committee.

This fourth podcast in our dedicated prior authorization (PA) series includes an engaging discussion with Dr.Khan about his experiences with PA in the private sector. He will share the burden of forms and paperwork for both public and private systems, the support received from patient support programs (PSPs), and how the private payer PA process could be improved.

Why Prior Authorization is Important to Physicians

Blogs

Working Towards New Solutions in Prior Authorization

Did you follow the Simplify Prior Authorization (SPA) initiative in the first half of 2021 after the release of the white paper on prior authorization (PA) in November 2020?

read more...

Prior Authorization – The Future for Insurers and PBMs

Find out more about the role of insurers and pharmacy benefit managers (PBMs), payers, in the prior authorization (PA) process.

read more...

Prior Authorization and the Impact on Physicians

During research for the Simplify Prior Authorization (SPA) white paper in 2020, we learned how the prior authorization (PA) workflow process was impacting prescribers. We heard that there are several areas that make current PA processes challenging for physicians in delivering care to their patients.

read more...
Supportive Handshake

How to Support Simplify Prior Authorization

We are building our financial support through sponsorship of this multi-stakeholder initiative. We also welcome contributions of time and expertise. To receive a copy of our sponsorship package contact us.

For More Information Contact

Denise Balch

denisebalch@connexhc.com

Gold

Silver

Get In Touch

If you have questions, are interested in finding out more about this initiative or providing support, please contact us.