Prior Authorizations: Realizing Their Potential

WithMe Team

Providers have long been vocal about their disdain for the current prior authorization process, which they see as a “purposely burdensome” waste of their valuable time, and a transparent attempt on the part of health plans to save money at the expense of what doctors believe is best for their patients. In a recent AMA survey, providers reported prior authorizations as one of the major problems “ruining medicine,” with more than 90% of physicians polled agreeing that prior authorizations have a negative impact on patient care.

Why do they have such a bad rap?

From a provider and patient perspective, obtaining a prior authorization can be a tedious and time consuming process. Providers are often required to manually fill out forms that must then be faxed to the PBM. In most cases it takes 1-3 days for the PBM to return a response to the provider’s original request, but it can take up to 5-10 days. If a patient’s original request is denied and their doctor appeals the decision, the process can be even further drawn out.

The more hoops that a provider has to jump through, and the longer a patient’s treatment is placed on hold while they await a response from their health plan, the less likely it is that the patient will ever begin that therapy. When a patient delays or abandons their prescribed therapy, their condition is often exacerbated, which can lead to other adverse health outcomes. This, in turn, often necessitates the need for more expensive interventions, such as an emergency room visit or hospitalization, that will drive up the plan sponsor’s total spend.

If they cause so much friction, why do prior authorizations exist?

Prior authorizations were designed to reduce risk

Prior authorizations help avoid medication errors. They provide a critical safety net to prevent potentially dangerous prescribing decisions by flagging drugs that are known to be unsafe when taken in conjunction with other medications, or drugs that are often misused or abused. In these cases, the prior authorization process gives the PBM the opportunity to review a patient’s existing prescriptions and prevent any potential adverse drug events.

They also reign in costs

Prior authorizations are one of the many “utilization management” strategies PBMs use to help mitigate plan sponsors’ rising drug costs. Before specific high-cost or brand name medications can be dispensed, providers are required to submit an official request and obtain permission from the patient’s PBM to ensure that patients are directed to the most cost-effective therapy available.

The Good News?

Technology is enabling vast improvements in how prior authorizations are processed. Two capabilities that are being broadly rolled out by PBMs, WithMe included, are:

Real Time Benefit Checks (RTBC): With the widespread adoption of electronic medical records (EMR), PBMs are able to integrate with these systems, enabling physicians to perform real time benefit checks, including whether the drug in question has a prior authorization requirement, and potentially prescribe an alternate while the patient is in the office.

Electronic Prior Authorization (ePA): As mentioned above, the traditional prior authorization process is tedious and outdated, requiring providers to manually fill out documents that are then faxed to PBMs. EMR integration is improving this process, enabling physicians to complete the necessary forms from within the patient’s EMR and electronically transmit them to the PBM.

These solutions are essential building blocks for WithMe, as we work to improve the process. But that is all they are - a jumping off point. Because while they enable physicians to more easily interact with PBMs around prior authorizations, the outcome of those interactions greatly depends on the quality of input. And that’s where WithMe Health’s approach to medication protocols makes a significant difference.

What is WithMe Health Doing Better?

WithMe’s goal is to make prior authorizations not just easier but as close to invisible as possible for the patient: if we do our job well, the patient won’t even know it was done. But when we can’t be invisible, we will be transparent with the member so that they know what’s going on. What exactly are we doing better?

Personalized Drug Selection: The foundation for this is our access to extensive patient data (including lab tests, medical and pharmacy data and clinical history across multiple prescribers) which ensures that we have a comprehensive and up-to-date view of individual considerations.

We combine this level of patient insight with robust criteria designed to mirror best practice standards and the latest applicable scientific literature.

The specificity of our criteria combined with the thoroughness of our patient data enables us to improve upfront drug selection, while at the same time reducing the frequency that prescribers encounter an unexpected prior authorization.

Preemptive Resolution: If we can see from the patient’s data that they meet the criteria for prior authorization, we will either preemptively remove the prior authorization requirement for the specific patient or we will work to resolve it automatically, without requiring additional information from the physician. The result: members start medication more quickly.

At a time in which PBMs are often requiring physicians to complete huge amounts of paperwork to justify prescribing, and provider practices have begun billing patients for this time, we think what was once a nuisance has become a hazard, and everyone will appreciate a newer, easier approach.

Proactive Engagement & Transparency: When a patient does require a prior authorization to be processed, we will instantly contact them and be in touch to let them know that we’re working through the process and will update them on the status every few hours until it’s resolved. Then we work with their provider to resolve any data points so that we can quickly get the member started on therapy.

If you’d like to learn more about these strategies and others we are implementing to improve patient experience and reduce plan sponsor spend, feel free to reach out to us at any time. We’d be happy to share.