Best Practices for Electronic Prior Authorization Integration in … · 2016-05-19 · Best...

Best Practices for Electronic Prior Authorization Integration in your Health System

Prepared by CoverMyMeds for CSOHIMSS

Introductions

C O N F I D E N T I A L © 2016 CoverMyMeds LLC. All Rights Reserved.

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


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.


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


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


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


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


Recent studies reflect 265 million claims a year result in prior authorization requests.

Time to Completion


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


Active Legislation

Pending Legislation

Legislation Inactive or Dead

No Current Legislation

Implementation Best Practices

1. Support All ePA Workflows


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


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


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


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


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


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


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


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


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

Best Practices for Electronic Prior Authorization Integration in … · 2016-05-19 · Best...

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