Best Practices for Electronic Prior Authorization...
Transcript of Best Practices for Electronic Prior Authorization...
Best Practices for Electronic Prior Authorization Integration in your Health System
Prepared by CoverMyMeds for CSOHIMSS
Introductions
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Erica Van Erica Van Erica Van Erica Van TreeseTreeseTreeseTreese, CAHIMSS, CAHIMSS, CAHIMSS, CAHIMSS
Account ManagerAccount ManagerAccount ManagerAccount ManagerHealth Systems
EEEE----mail: mail: mail: mail: [email protected]@[email protected]@covermymeds.com
Nick Anderson, CPHIMSSNick Anderson, CPHIMSSNick Anderson, CPHIMSSNick Anderson, CPHIMSS
Product Implementation LeadProduct Implementation LeadProduct Implementation LeadProduct Implementation LeadHealth Systems
EEEE----mail: [email protected]: [email protected]: [email protected]: [email protected]
Prior Authorization Overview
Prior Authorization, Automated
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CoverMyMeds is the nation’s largest Electronic Prior Authorization (ePA)
solution and one of the fastest growing healthcare technology
companies in the U.S.
We help physicians, pharmacists and their staff complete ePA requests
for any drug and all health insurance plans.
© 2015 CoverMyMeds LLC. All Rights Reserved.
© 2015 CoverMyMeds LLC. All Rights Reserved.
Prior Authorization [prahy-er aw-ther-uh-zey-shun]
noun
1. A health plan’s way of requiring prescribers to justify why their
patient needs one medication over another. In many cases, a PA is
needed when there are cheaper or more effective alternatives to
the medication being prescribed, often generics.
What is PA?
Types of PAs
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Quantity Limit – The plan may limit the number (or
amount) of drugs covered within a certain time period.
Step Therapy – The plan requires the patient to begin
medication with the most cost-effective and safest drug
therapy, and progress to other more costly or risky
therapies only if necessary.
Non-Formulary – Most formularies cover at least one drug
in each drug class, all other drugs in the same class would
be considered off the plan’s formulary, or Non-Formulary.
PA Required – The plan will need to review a medication
before it will be covered. This can apply to both brands and
generics.
Prior Authorizations can be required for the following reasons:
NCPDP SCRIPT Transaction
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Part 1: Part 1: Part 1: Part 1: Patient and drug information submitted to plan
Part Part Part Part 2: 2: 2: 2: Questions provided based on patient, drug and plan
Part 3Part 3Part 3Part 3: : : : Answers submitted to plan
Part Part Part Part 4: 4: 4: 4: Determination returned to provider
Administrative Waste
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More than 50% of prescribers indicate
that they and their staff spend up to 20
hours per week on PA requests
Pharmacists spend an average of 5
hours per week on PA requests
Abandoned Prescriptions
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Recent studies reflect 265 million claims a year result in prior authorization requests.
Time to Completion
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Pre-Electronic eFax True ePA
Completion 15-20 Minutes 3-5 MinutesWeb: 3-5 Minutes
EHR: Seconds
Turnaround Time 3-5 Business Days 2-4 Business DaysApproval: Real-Time
Denial: Less than 24 Hours
ePA: Legislation
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Active Legislation
Pending Legislation
Legislation Inactive or Dead
No Current Legislation
Implementation Best Practices
1. Support All ePA Workflows
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RETROSPECT IVE
Ability to receive PA
requests started by a
pharmacy
PROSPECT IVE
Allows prescriber to start a
PA request in E-Prescribing
workflow
Prospective vs. Retrospective
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The percentage of prospective requests include those started by the pharmacy outside of an electronic workflow,
which results in the appearance of being prospective when it was actually initiated by the prescriber through
CoverMyMeds. Therefore, the actual percentage is likely much smaller than 29%.
29%PROSPECTIVE REQUESTS
71%RETROSPECTIVE REQUESTS
2. Establish your System’s Current Workflow
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A successful ePA Rollout is dependent on identifying who needs access and who needs to be trained.
Critical Workflow Factors
• The “Who” is the most critical factor. Knowing whether individual physicians, teams, or centralized groups work PA is critical to successful rollout
• Training and configurations within your EHR will vary based on how the PA process has been self organized
• Sometimes, as with Inpatient Discharge Meds, the technology is less limiting than the lack of ownership
• Interaction between owned Pharmacies and Providers also is important to iron out
• Your ePA vendor should be able to help tailor a project plan that accounts for these process deviations
3. Evaluate Your Current Payer Mix
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Not all Plans / PBMs support ePA and those that do are not 100% ePA.
Payers Vary in Capabilities
• Talk to your ePA vendor to review your top utilized PBMs and determine how electronic they are. This should help set impact expectations
• Identify the volume of PA requests or ePA requests the vendor does with your most frequently used Plans
• Reach out to your highest volume, non-ePA Plans to identify their timelines for becoming electronic
4. Measured and Steady Rollout
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Your initial Rollout should be a pilot site and subsequently move to additional offices / sites / regions
Always start with a Pilot site
• Starting with a Pilot will allow you to work out any technology issues quickly and with minimal impact
• It will allow you to better evaluate what training strategy will be effective
• The Pilot site will ideally be practices who already are familiar with electronic PA or are more technically savvy. Use their success as a meaningful example for other locations
• Track metrics to ensure objectives are being met
5. Collect Pharmacy Benefit Info Early
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The more streamlined the ePA process, the easier it is to access the patients Pharmacy Benefits
Not Just Medical Benefits
• Separate numbers and contacts from Medical benefit
• Some Payers and Plans provide separate PBM Cards. Train your registration staff to collect all cards
• If possible, verify eligibility the day prior
6. Communication and Training
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Training
• Depends on size and geographic spread
• Most effective is elbow support during pilot, hands on group trainings by building or region in later rollouts
• Work with your ePA vendor to create quick reference guides, videos or alternative solutions
• Identify follow up or support path if questions arise post Go-Live
Communication
• Communicate to your providers and their staff about the change, the schedule, and benefits
• Work with your ePA vendor to get collateral
• Don’t just mass email. Use multiple channels of communication and reach out to key office stakeholders
7. Centralize the PA Function
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Focus Centrally
• Familiarization will allow for faster turnaround and processing time saving additional resources
• Allows providers to focus on direct patient care by removing additional administrative burden
• Allows for specialization on drugs, treatments, or payers. Knowing how to navigate these areas effectively leads to higher approval rates
• Provides avenue for completing PA needed for Discharge medications
Not a first step, but longer term focus towards increasing efficiency
CoverMyMeds
Largest Platform
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500+Integrated EHRs
46,000+Pharmacies
500,000+Prescribers
75%Of Prescription Volume
Payers Representing Nearly
80%Of Pharmacy Market
Total CMM PA Volume- PA is what we do
CoverMyMeds will initiate more than 20 M
PAs for Health Plans and PBM’s in 2016.
Volume is increasing from spectrum of
sources:
• EHR integrations
• National PBM roll outs
• Provider Adoption activities
• Additional Pharmacy deployments