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

Dr. Neil Shear and Denise Balch will speak about the advances of dermatology as a profession and in the available treatments for dermatology patients. They explore some of the complex and debilitating dermatological diseases that can lead to mental health issues, withdrawal from society, and an inability to work if not treated effectively. They also discuss treatment progression protocols and the impact of newer treatments that are prescribed for patients who do not respond well to traditional therapies.

Dermatology, Treatment Progression and Prior Authorization

Blogs

Specialty Drugs and Prior Authorization: Challenges and Solutions – Summer Webinar 2022

On June 22, 2022, the Simplify Prior Authorization (SPA) initiative hosted the third 2022 webinar, this time with insurers, pharmacy benefit managers, and patient support programs as our target audience. The webinar explored the current prior authorization (PA) process in the private and public sector, the progress towards a viable electronic prior authorization (ePA) solution to improve the process and a new online education resource for stakeholders currently under development.

read more...

Challenges and New Solutions in the Prior Authorization Landscape

On April 19th and May 3rd, 2022, the Simplify Prior Authorization (SPA) initiative hosted webinars for patient groups and advisors/plan sponsors on the Challenges and New Solutions in the Private Prior Authorization Landscape.

read more...

Addressing the Backlog of Cancer Patients

Canadians with cancer have been experiencing longer times to diagnosis and medical treatment during the pandemic.

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

Platinum Sponsor

Gold Sponsors

Silver Sponsors

Get In Touch

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