Spending an hour or longer on hold trying to find a straight answer on whether a medication needs authorization is not the best use of any registrar’s time. Neither is sending faxes back and forth to prove the drug is medically necessary. In the patient access world, these inefficient practices are common. That is because most authorization requests are handled manually: by mail, fax, phone, web portals, or a combination of these. “The percentage of prior auths that are done electronically today is pretty low. We’ve been tracking it at about 13%,” says April Todd, senior vice president of the committee on operating rules for information exchange (CORE) and explorations for CAQH.
CAQH, a nonprofit that seeks to streamline healthcare business practices, recently approved two sets of standards: one for consistent use of data content, and a second for response times, which health plans, providers, vendors, and governmental entities have agreed on.1 “Getting everyone to come together on those two things is pretty significant,” Todd shares. CAQH CORE is in the process of recommending rules to Health and Human Services (HHS) for federal mandate under the Health Insurance Portability and Accountability Act (HIPAA). If HHS mandates these recommendations, all HIPAA-covered entities would have to follow them. “Hopefully, things should start to change and move in a good direction,” Todd says. The authors of a July 2019 white paper2 identified these barriers to automating the auth process:
• Clinical and administrative systems used within health systems often are not integrated. When payers request clinical information before agreeing to authorize a service, there is no easy way for patient access staff to obtain it. “This continues to be a problem. Providers have to essentially copy and paste information from their EMR to the other systems,” Todd explains.
• There are no federally mandated standards on how providers communicate clinical information to health plans. “The industry has been waiting for HHS to set this standard for a long time,” Todd says. The currently agreed-upon rules go only so far. Once HHS sets the standard, “we’ll be ready to act very quickly to fill this gap that is making prior authorization more complicated,” Todd adds.
• Vendors are not offering products that solve the problem. Some patient access departments turn to vendors in the hopes they can automate auths, only to find the products are not there yet. Vendors are hesitant to develop solutions that they will have to change later. “We are hopeful that these rules going into place — that will create some standardization, will give vendors the impetus to develop products to comply with it,” Todd says. Despite many obstacles, there is a great deal of momentum toward finally fixing the problem of prior authorizations. The timing is right for automation, according to Todd. “If you look historically at how the healthcare industry has moved to automate things, prior authorization is the next logical place to go,” she says.
The vast majority of high-volume processes in healthcare are automated, according to the 2019 CAQH Index.3 Almost all (96%) claim submission, 84% of eligibility and benefits verification, and 86% of coordination of benefits are conducted electronically.
According to the 2019 CAQH Index, it takes providers an average of 21 minutes to submit authorization requests manually. This compares to four minutes if it’s handled electronically. “If you add up that savings of 17 minutes for every transaction, it’s a lot of time saved,” Todd shares.
Prior authorization practices for medications at eight community providers in Tucson, AZ, are in urgent need of modernization, according to the authors of a recent analysis.4 “We did this study to provide some empiric evidence about the process. We hope that this information will be used to improve the system,” says Terri Warholak, PhD, one of the study’s authors.
None of the providers used electronic prior authorization solutions at the time of the study. Staff were largely unaware these existed. Some college students who collected data for the study, most of whom were millennials without a healthcare background, were shocked that prior authorization requests are handled via fax. “Many of them had never seen this antiquated technology in use before,” Warholak says.
If electronic prior authorization was implemented fully, “the extra hours, and hence the cost, put in by the providers and their staff can be reduced significantly,” says Sandipan Bhattacharjee, MS, PhD, the study’s lead author.
Many patients have no idea about all the work that happens to obtain an auth. “Currently, patients are largely shielded from the process,” says Anita C. Murcko, MD, FACP, another of the study’s authors. Providers and patient access employees are left to update patients on the status of the auth. “There is a slow movement toward transparency, standardization of questions and formats, and improving EHR integration,” Murcko adds.
- CAQH CORE phase V operating rules. Available at: http://bit.ly/2TALoc6.
- CAQH CORE. Moving forward: Building momentum for an automated prior authorization adjudication process. Available at: http://bit.ly/2Igrhus.
- 2019 CAQH Index. Conducting electronic business transactions: Why greater harmonization across the industry is needed. Available at: http://bit.ly/38iBEZk.
- Bhattacharjee S, Murcko AC, Fair MK, Warholak TL. Medication prior authorization from the providers perspective: A prospective observational study. Res Social Adm Pharm 2019;15:1138-1144.