Patient Questions Regarding Prior Authorization

Prior Authorization Question and Answer (Q&A) – What You Need to Know

On the November 26, 2020 Benefits Breakfast Club webinar experts addressed innovations in oncology and the role of prior authorization (PA), including the many challenges of a largely paper-based PA process. While not exclusive to oncology, PA is often required by payers (insurers or pharmacy benefit managers (PBMs)) for newer oral or infused oncology medication as well as drugs in other categories either because of high cost or high volume.

At the session there were questions we did not have time to address. Bev Herczegh of The Pangaea Group and Denise Balch of Connex Health Consulting, co-authors of a recent white paper on PA, have prepared this question and answer guide for information purposes.

Q: What exactly is prior authorization (PA) and why should I care?

Prior authorization is a process used by payers to evaluate whether a claim meets certain clinical criteria for reimbursement based on medical information presented to them by the patient and their physician. Current prior authorization processes include a lot of paper shuffling between payers, physicians, patients and patient assistance programs. This is time consuming for everyone involved and expensive, more expensive than an electronic prior authorization claims submission process would be. More time in gathering information means patient delays in accessing their medication, higher costs for payers, and higher administration fees for plan sponsors. If you are a plan advisor or plan sponsor this should concern you.

Q: What were the highlights of the white paper research on prior authorization?

Connex Health Consulting and The Pangaea Group spoke to payers, medical professionals, patient access navigators, advisors and plan sponsors as part of their research for the white paper. Here’s what they found:

  • The high administration burden could be addressed by more consistency and transparency in the process, a standardization of claim forms to the extent possible, and a move to electronic prior authorization

  • There are discrepancies in grandfathering prior authorization claims on change of carrier

  • There is a lack of metrics or evaluations that could be used to identify opportunities to improve the process.

Q: Who will benefit?

Most importantly, results indicated that patients will benefit from a more efficient, online process. In reality, every stakeholder in the current process is likely to benefit. Doctors will spend less time filling out paper forms and payers will spend less time reviewing claim forms and corresponding back and forth to doctors.

Q: Who is paying for the Simplify Prior Authorization (SPA) initiative?

The initial white paper and the seed money for this initiative came from pharmaceutical manufacturers. Without question they have an interest in ensuring patients receive timely access to medications. Recognizing this, the white paper recommended that any change initiative should be a collaborative process that is funded by multiple stakeholders; to address any bias and to demonstrate the commitment of everyone involved in the SPA initiative to create positive change to simplify PA.

Q: What about payer autonomy?

It is understood that payers must have autonomy over their list of PA drugs, the clinical criteria they consider, and how clinical criteria is applied internally when adjudicating claims. Outside of this, there is reason to move forward with the efficiencies that would be created by an online portal offering access to claim forms, lists of PA drugs by payer and, most importantly, an online PA claims process or electronic prior authorization (ePA).

Q: Will there be a financial benefit to moving to an electronic prior authorization (ePA) process?

We think so. This is part of the work for the Simplify Prior Authorization initiative; to identify where efficiencies can be implemented and to quantify the ROI of improving the process.

We can and we must do better. When we do, we all benefit.

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