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Doctor talking to insurance representative, shaking hands
Doctor talking to insurance representative, shaking hands

Minimizing Disruptions to Continuity of Care

Since 2020 the Simplify Prior Authorization initiative has been advocating for improvements in the process, including electronic prior authorization.

In the fifth of our six-part series examining the prior authorization (PA) process in Canada vs. the U.S. we address the importance of the continuity of patient care. You can find links to our other blogs in this series here. 

Why Continuity of Care is Critical to Health Outcomes

Whether a patient is diagnosed with a relatively common chronic disease or a complex disease that is treated with specialty medications, continuity of care i.e. ensuring an individual’s care is continuous and connected over time, is critical to positive health outcomes. When there is a break in continuity of care, including access to prescribed medications, diagnostic tests, or healthcare professionals, health outcomes may be impacted, which can also result in presenteeism or absenteeism at work.

When Do Disruptions in Continuity of Care Happen in Group Benefit Plans?

Disruptions can occur when a plan member changes jobs and their new plan does not cover their prescribed medication, or when there is a change in prior authorization criteria under an existing group plan, a loss of coverage because of formulary changes within an existing group plan, or on change of insurance carrier. Anytime the formulary or prior authorization criteria changes, or there is a change in carrier, plan members are at risk. Plan members, advisors and plan sponsors may not be aware of the risk of loss of coverage and a disruption in continuity of care. These disruptions can have negative consequences for the health of a patient and at work.

The Canadian Context

In Canada, changes in insurance carrier is of particular risk for patients who are approved for medication through prior authorization. Grandfathering rules in the group insurance industry in Canada do not apply to drug plan formularies and prior authorization approvals on change of carrier. It is up to the advisor to ensure the continuity of care when group coverage moves between carriers and negotiate any exceptions if the new plan formulary does not include coverage for a PA medication that has already been approved by the existing carrier. This is an additional administrative burden for advisors when the task could be taken on by insurers or those who administer prior authorization on their behalf.

Even if insurers exchange a list of patients who are approved for prior authorization medication, there are no guarantees reimbursement will continue. Patients may lose coverage if the formulary has changed, the list of approved indications for a particular medication are different, or where the PA criteria differs. Consistency at an industry level on how carriers manage changes in coverage situations for patients already being reimbursed for medications is overdue.

How is Continuity of Coverage Addressed in the U.S.?

State legislation in Minnesota (62M.17) addresses this issue:

  • If the new health plan uses different utilization review from the old plan, the new plan must comply with the PA approval from the previous health plan for at least the first 60 days, giving the patient time to source other coverage or other sources of reimbursement.
  • If coverage terms or clinical criteria for PA change during a plan year, the change in will not apply until the next plan year for any plan member who previously received PA.

Addressing Continuity of Care in Canada

Through the new Prior Authorization Framework and Accreditation (PAFA) program launching in Spring 2024, insurers can use a voluntary framework to ensure reasonable continuity of care for patients already approved for prior authorization medication. Continuity of care is addressed in the framework for temporary changes in medication, renewal of prior authorization claims, and changes in coverage because of formulary change or a change in carrier.

The Prior Authorization Framework and Accreditation (PAFA) program is an initiative of Simplify Prior Authorization. The goal of PAFA is to provide an objective evaluation and accreditation tool of payer prior authorization claims (PA) administration processes and practices in Canada. It is the result of extensive research and input from multi stakeholders and subject matter experts, including those who participated in the 2020 Report on Private Payer Prior Authorization in Canada: Simplify Prior Authorization, by Connex Health and the Pangaea Group.

The PAFA can be used by payers to evaluate their own processes and make the adjustments necessary to meet the framework’s criteria and receive accreditation and recognition. Nonpayer stakeholders can use PAFA to evaluate a payer’s PA practices against the guiding principles, framework, and their accreditation status.

For more information on PAFA membership, associate membership, and accreditation contact info@simplifypriorauth.ca.

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