As first seen on Fierce Healthcare
By: Christie Callahan, Chief Operating Officer, Arrive Health
Prior authorization (PA) is a balancing act designed to manage utilization on the one hand and ensure that patients receive necessary, cost-effective treatments on the other. In today’s health care landscape, though, many providers view the traditional PA process as a necessary hurdle that often causes unnecessary care disruptions. PAs take physicians and their staff ~12 hours each week to complete, creating significant administrative burden. Moreover, according to a recent survey, 87% of physicians report that PAs led to higher utilization of health care resources and 24% say that PA has led to a serious adverse event for a patient in their care.
The integration of real-time prescription benefit (RTPB) tools with electronic prior authorization (ePA) systems presents a transformative opportunity, enabling providers and payers to fulfill the intended purpose of PA—managing medication use and costs without sacrificing optimized patient care.
Role of Prior Authorization in Health care
The intent behind PA is to avoid unnecessary treatments, manage health care expenditures, and provide the most effective care based on scientific evidence and clinical guidelines. However, the traditional PA process is hampered by drawbacks, including the time and resources needed to complete paperwork and the high probability of treatment abandonment post-denial. On average, physicians complete 43 PAs per week and 27% report their PAs are often or always denied.1
Integrating RTPB and ePA
RTPB tools provide patient-specific prescription benefit information at the point of prescribing, offering instant visibility into drug coverage, utilization management scenarios, and out-of-pocket costs. This allows providers and patients to make informed decisions and expands the range of treatment options by offering covered or unrestricted formulary alternatives.
When the PA process is technology enabled through ePA systems, providers submit electronic requests regarding PA requirements electronically and receive timely payer responses. This real-time process reduces unnecessary paperwork, phone calls, and faxes, thereby expediting approvals and minimizing treatment delays.
When you combine RTPB and ePA, a new paradigm is possible. Providers no longer wait for a denied claim at the pharmacy to start a PA. Patients no longer wait days for PA resolution. Instead, RTPB allows the best medication choice at prescribing, immediately initiates an ePA when PA is required, and a PA decision is received in hours. All allowing the patient to pick up their medication on the same day.
Realizing the Intent of Prior Authorization Through Integration
The integration of RTPB and ePA enables both providers and payers to fulfill the core objectives of prior authorization. Both actions occur seamlessly within electronic health record (EHR) systems, streamlining the workflow and reducing administrative burden.
- Formulary adherence and cost control
Providers view formulary alternatives and their associated costs, encouraging the selection of cost-effective therapies based on each patient’s unique insurance coverage.
- Timely access to care
Providers make informed decisions in real time, reducing the likelihood of prescribing medications that require PA or will face PA denial, and when a PA is required, it is automatically started.
- Greater transparency, choice, and affordability
Patients fully understand their treatment options at the point of care, avoiding surprises and delays at the pharmacy, and are informed throughout their treatment journey.
By automating the PA process and spotlighting expanded access opportunities, RTPB and ePA integration frees up provider resources to focus on patient care, minimizes the administrative workload for payers, and accelerates patient access to medication.
Optimizing for Replicable Outcomes
Both RTPB and ePA are tools that have been leveraged by providers and their staff for years. While driving initial efficiency gains, the full promise of these tools has not been fulfilled. PA is still highlighted as the #1 barrier to medication adherence with 88% of physicians noting that PA interferes with continuity of patient care. 1 In addition, a significant majority of physicians report that the number of PAs required for prescription medications (83%) and medical services (82%) has increased over the last 5 years.
Out-of-the box solutions are not enough. RTPB and ePA should not be used independently but should be paired together to ensure the best results. New technologies, like large language models, must also be applied to share information differently. These technological advances are not just possibilities but are a reality that offer unmatched benefits as compared to the current state.
- Enhancing prescribing accuracy and efficiency
Conferring providers with access to real-time benefit information and PA criteria empowers providers to make evidence-based treatment decisions that are more likely to be approved by payers, reducing the incidence of denials and appeals. - Decreasing the number of denials and appeals
The integration of RTPB and ePA puts clear, real-time guidance on coverage requirements at the fingertips of physicians, clarifying the PA process and preventing PA requests that do not meet coverage criteria. - Supporting shared clinical decision-making
Access at prescribing facilitates provider-patient communication, enabling shared decision-making that considers each patient’s unique treatment preferences and financial realities. This collaboration strengthens the provider-patient relationship and encourages patients to be their own advocates, leading to greater satisfaction and reducing the likelihood of non-adherence.
Key Takeaways
The future of health care lies in widespread utilization of fit-for-purpose technologies that enhance the interactions among providers, payers, and patients. The right integration of RTPB tools and ePA systems can represent a leap forward in the efficiency and effectiveness of the PA process, providing a strong incentive to allow providers to operate at the top of their license. The coupling of these technologies helps realize the true intent of PA—ensuring that patients receive appropriate, cost-effective care without unnecessary delays. Ultimately, increased transparency can optimize prescribing behavior, leading to better outcomes for patients and more value-driven investment of health care resources.
American Medical Association. 2023 AMA prior authorization physician survey. Available at https://www.ama-assn.org/system/files/prior-authorization-survey.pdf.
This article originally appeared on Fierce Healthcare.
