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HIT Think Taking the Guesswork Out of Prior Authorization

Published
  • August 24 2014, 5:36pm EDT

“Is this medication covered by my patient’s health insurance plan?” This frustrating question is faced many times each day by physicians.  Getting drug coverage answers is often tedious and time consuming due to the ubiquitous presence of prior authorization, a managed care mainstay for cost savings and patient safety.  But prior authorization (PA) -- that unreimbursed yet unavoidable anachronism -- is not going anywhere anytime soon. In fact, as more drugs become available and more beneficiaries enter the insurance pool, the use of PA is becoming more prominent.

Although only roughly 5 percent of prescriptions are subject to prior authorization, the time spent on these processes is significant.  A recent study by the Center for Health Care Transformation found that on average, physicians spend more time dealing with drug PAs than any other health plan interaction. An AMA survey of 2,400 physicians found that many were spending up to 20 hours per week on PA requests.  To add to this burden, formulary and eligibility information is often difficult to interpret or is incomplete.  Additionally, the PA requirements and the related forms and formats differ by health plan, drug class and drug, making documentation and submission time- and labor-intensive for all involved. Up to 90 percent of PA requests require a fax or phone call.

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