As one provider told us in a national survey, “Prior authorizations are the pits!” This sentiment is shared widely both in and outside of the healthcare industry, and deservedly so. I am a patient, and I’ve experienced the confusing and slow prior authorization approval process, waiting anxiously for the green light to go pick up the medication I need. But working in healthcare also gives me insider knowledge to understand that prior authorizations themselves aren’t to blame; rather it’s the processes used to review and approve them that have created a bottleneck that must be cleared if we’re to improve patient access and lighten the provider workload.
While prior authorization represents just one touchpoint on a patient’s medication adherence journey, it creates significant friction (specifically high volumes of phone calls and faxes between pharmacies, patients, doctors, and insurance companies) that ultimately delays access to medications. Sometimes providers and patients know about the prior authorization, but many times they are blindsided – only finding out at the pharmacy counter that their insurer has rejected coverage.
The lack of transparency throughout the prior authorization approval process creates treatment delays, additional work, low adherence and outcomes, and a tremendous amount of strain on the patient-doctor relationship. With healthcare providers spending an average of 14 hours each (~700 hours a year!) completing prior authorizations, and a staggering 37% of prescriptions initially rejected at the pharmacy being abandoned by discouraged patients, there is no time to waste in overcoming the bottleneck by infusing more visibility into the approval process.
Three examples of how to make prior authorization work more effectively
Solving for prior authorization starts with data, specifically giving patients and healthcare providers access to clear and timely information about which medications are covered by insurance plans before the patient leaves the doctor’s office. This is because when providers start the prescribing process with accurate data, they unlock multiple opportunities to reduce friction and create a more streamlined patient and provider experience.
Here are three examples of what’s possible when real-time cost and coverage data is considered from the start:
- First, providers can use Real-Time Prescription Benefit (RTPB) data to see which medications require prior authorization and which alternative medications don’t have restrictions. With this visibility, providers can often avoid a prior authorization in the first place – upwards of 30% of the time as we’ve seen with engaged providers for one PBM partner.
- If prior authorization cannot be avoided, doctors can use RTPB to reduce surprises by educating the patient that prior authorization is required and that they need approval before they can get their medication. They can also use integrated, prospective prior authorization capabilities to automatically start the approval process – eliminating the denied claim and thereby avoiding the deluge of phone calls and faxes typically needed to resolve a prior authorization. Using technology in this way speeds access to medication to <4 hours, compared to the typical 3-to-4-day wait.
- Finally, automation capabilities can proactively update patients about approval status. Text messages with short updates like “Your prior authorization has been submitted for approval.”, or “Your prior authorization has been approved and you can go to your pharmacy now.” can not only create good patient experiences but also reduce the mountain of phone calls providers and pharmacies currently have to manage.
Today’s reliance on existing tools and the (often largely manual) processes to accommodate them is leaving an immense amount of opportunity for improvement on the table. We have the capabilities to improve patient and provider satisfaction, ensure patients receive (and stay on) necessary medications in a timely and hassle-free manner, and we can drive better quality care and health outcomes. The only thing holding us back is widespread adoption of them.
