Electronic Prior Authorization

Until recently, the environment has not been right for a move to electronic prior authorization (ePA). Insurer payers, at least some of whom have met to discuss ePA, had not been presented with an ePA solution that could address concerns about the proprietary nature of their prior authorization claims process and prior authorization criteria.

Insurer payers understandably want to protect their proprietary adjudication criteria which is often presented as part of their product differentiation strategy to attract new clients and retain existing ones.

Another reason ePA hasn’t happened yet is the challenge of meeting the diverse needs of the many stakeholders in the prior authorization environment with a single solution.

• Multiple stakeholders in the prior authorization process have evolved over the last 20 years or so and each has a unique role in the prior authorization claims process.
• At one time only physicians, pharmacists, insurer payers and patients needed to be considered in any prior authorization process.
• Now there are also dedicated patient support programs (PSPs), patient access programs (PAPs), drug access navigators (DANs) (usually oncology), and often pharmacy benefit managers (PBMs) that are an integral part of the prior authorization landscape.

The pressure to adopt an ePA solution has been growing. As the number of specialty drugs continues to grow in the Canadian landscape the list of drugs subject to prior authorization lists by payers is also growing. This results in a higher administrative burden and therefore cost for all prior authorization stakeholders. An ePA process would reduce this burden.