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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. Presenters included Rachael Manion, Executive Director of Canadian Skin Patient Alliance and Canadian Association of Psoriasis Patients, Alan Birch, Associate Director of Provider Solutions – Oncology with Sentrex and founder of Drug Access Canada, and Denise Balch, President of Connex Health.

Prior authorization is a process by which private payers (insurers and pharmacy benefit managers (PBMs)) reimburse a prescribed medication on the submission of satisfactory medical evidence from a patient and their physician according to criteria established by payers. Based on the 2019 White Paper from Connex Health and reinforced by presenters at the webinars, PA is time-consuming due to inefficiencies in the process that include:

  • 1Manual completion of paperwork requiring wet signatures from patients and their physicians
  • 2Printing and attaching additional information for mail or fax to insurers, documentation which can be lost or where content legibility can be degraded via fax
  • 3Manual input and processing of a claim by payers.

As a result, patients can sometimes be left waiting weeks before they can start treatment. This can have a significant impact on patients. Not only can the administrative process be frustrating and stressful, for some, there is a risk of significant disease progression which can result in irreversible debilitation or exacerbation of their condition.

The public sector has traditionally faced similar process challenges. Recently there has been significant improvement in the public sector process through the implementation of Special Authorization Digital Information Exchange (SADIE), an electronic online submission tool which can process claims within 1-2 business days. The private sector has yet to see any updates of this kind.

Simplify Prior Authorization (SPA)

In the original White Paper and through advocacy and outreach such as recent podcasts and webinars, the SPA initiative is advocating for the implementation of an agnostic and seamless, electronic process for reimbursement of PA claims. This enables healthcare practitioners, drug access navigators (DANs), some specialty pharmacies, and patient support programs (PSP) to complete and submit claim requirements electronically, including the collection of signatures, and required medical documentation. When payers receive the electronic submission, their PA team can review each claim submission and respond electronically, with an approval, request for additional information, or a decline.

An electronic PA process would not change the reimbursement decision, which would continue to be decided by payers. The criteria used to determine who qualifies for reimbursement would remain unchanged. However, an electronic prior authorization process (ePA) will decrease submission and wait times for payer decisions on reimbursement, while also reducing the administrative costs associated with the existing long and inefficient process. The overall result is a more efficient process for all stakeholders.

Polling during the recent webinars told us there is also a stakeholder education and information gap when it comes to PA:

  • /Patient group representatives reported that over half of patient information inquiries regarding PA focus on the claims process and what to do if their claim has been declined, while approximately half were asking for help in facilitating their claim.
  • /For plan advisors and plan sponsors, over half of patient inquiries regarding PA focus on why their drug isn’t available or reimbursed at their local pharmacy, and just under half, why their claim for a specialty drug has been denied.

Additional discussion and polling results show that the PA web resource under development by the SPA initiative through Connex Health, could fill at least some information gaps, links to PA resources/payer websites and education on specialty drugs and the claims process.

Full polling results can be found here..

The information provided by participants in these webinars reinforces the need to improve the PA process and provide additional online resources where stakeholders can access information and education on PA. The SPA initiative will be addressing the need for a web resource in the coming months and welcomes additional input on content from all PA stakeholders, including payers, so that we can maximize the value of this resource.

Thank you to everyone who joined us at these webinars. We will be holding a third SPA webinar on June 22nd for insurers and PSP based on gathered interest. You can register for the third SPA webinar here.

If you represent a patient group, are a plan advisor or plan sponsor and missed one of our last two webinars, please join us on June 22!

All inquiries regarding the SPA initiative should be directed to Denise Balch at
denisebalch@connexhc.com. You can find past blogs and podcasts at www.simplifypriorauth.ca.


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