Pharmacists continuously strive to provide new, comprehensive and valuable services to ensure better care for patients. With the rapid adoption of electronic prior authorization (ePA), many find it is an effective way to free up staff by moving away from an archaic paper workflow to allow time to accomplish other goals. An added bonus: ePA succeeds in assisting in the ultimate healthcare objectives for a pharmacy by reducing prescription abandonment and ensuring patients leave the pharmacy on the first visit with their intended medication in hand.
The ePA National Adoption Scorecard, an industry collaborative effort released by CoverMyMeds, compiles data from several sources to give an accurate overview of the status of ePA adoption and implementation. Having this arsenal of information assists in making a strong case for the movement to an electronic solution. The question is: How does ePA accomplish the task of reducing prescription abandonment, eliminating administrative waste and promoting a more seamless relationship between pharmacies, pharmacy benefit managers (PBMs), prescribers and plans?
What is ePA?
An ePA is the online automation of information that is required by health plans to approve or deny a drug (or drugs) for a specific patient. Think of prior authorization (PA), in general, as a permission slip. It’s a go ahead from the patient’s health plan to fill the medication prescribed. It can also help ensure the patient is provided the correct dosage of medication and assist in pinpointing whether or not there is a less expensive alternative that would provide the same level of efficacy.
As found in the Scorecard, the average time a pharmacist spends processing traditional, paper-based PA requests is five hours per week. Within the paper-based fax and mail PA model, there is too much back and forth between the dispensing pharmacy, the prescriber and the health plan or PBM, causing a significant delay in therapy for the patient.
Because of the arduous and time-consuming process found in the paper-PA model, prescriptions are being abandoned, on average, 40 percent of the time. The consequences of prescription abandonment can potentially lead to disease progression, uncontrolled vitals, poor therapeutic outcomes and, in extreme cases, death.
What ePA does is move the strenuous, paper-based process to a streamlined, real-time, electronic solution. The disjointed workflow of using phones and fax machines to finish PA requests is a thing of the past. The present and future is ePA.
How does it work?
ePA is a four-part transaction maintained by the National Council for Prescription Drug Programs (NCPDP) and defined within the SCRIPT Standard. The transaction is unique to the particular patient, drug prescribed and health plan/PBM. As with the paper-based PA, the health plan/PBM defines the patient and drug-specific criteria to best make a determination, but because of the electronic capabilities ePA provides, the criteria can be automated to assist in real-time determinations for the pharmacy, prescriber and patient.
Scenario: A patient visits his doctor and is prescribed a medication that requires a drug PA. The prescribing physician or pharmacist chooses an electronic solution to begin the PA.
The ePA process can begin either prospectively (at the point of e-Prescribing by the physician) or retrospectively (after a claim is rejected). Today, 70 percent of PA requests are started at the pharmacy.
A pharmacy-initiated PA request is completed with the following steps:
- The pharmacist receives a PA-related claim rejection. He electronically initiates a PA request within the pharmacy system or via an online web portal.
- The prescriber is notified and retrieves the PA in progress through a web portal or his electronic health record (EHR) system. The remaining information is completed and electronically submitted to the insurance plan.
- If necessary, the plan electronically returns additional clinical questions to process the PA in order to make a determination.
- A decision is made and electronically returned.
Simple, effective and not a scrap of paper has to be moved and the pharmacy workflow is not interrupted.
ePA and Pharmacies
When it comes to ePA, pharmacies continue to lead in adoption and implementation. Currently, 87 percent of pharmacies are committed to an electronic solution and 70 percent are actively using this streamlined process.
The benefits are numerous:
- ePA is easy to use; the majority of pharmacy system vendors are integrated with ePA vendors to truly make the experience as simple as the click of a button.
- The level of patient care and transparency at the pharmacy is increased, resulting in elevated patient adherence and improved therapeutic outcomes.
- Electronic methods give the pharmacy direct access to real-time responses.
So why are some independent pharmacies still not using this technology?
The most common reason why pharmacists are not utilizing an electronic solution is they are possibly unaware the service is available to them directly through their pharmacy system. It is also possible they are aware of the solution but want to wait until their pharmacies are integrated with software/dispensing systems or until they are educated on the viability of a web-portal solution. Once the benefits are known, and they have been educated on the best way to utilize them, they are likely to adopt. The ePA process is intuitive, streamlined and often results in real-time coverage decision responses. When utilized, ePA can increase productivity and free up time for more important, revenue-based tasks, such as immunizations and discussing health outcomes with patients.
ePA in Legislation
Pharmacies should also take note that with the creation of the NCPDP named ePA Standard (SCRIPT Standard) and the increase in prescription PA, these legislative initiatives have become more prevalent at the state level. At present, 25 states have implemented legislation relating to the PA process. These laws range from the use of standardized forms for submission to mandating the use of the NCPDP SCRIPT ePA standard transactions. Additionally, many PA laws mandate specific timeframes for payers to provide a determination for both standard and urgent or expedited requests. Since PA legislation is currently only regulated at the state level, there is a large amount of variability between states. Among the remaining states that do not currently have legislation regarding PA, some currently have pending bills, such as Missouri, New Jersey, New York and Ohio.
Paper-Based PA to ePA
We’re still a long way from 100 percent ePA adoption, but with more stakeholders in the healthcare industry taking note of what it can do for patient care, as well as state governments picking up on the benefits, the needle on ePA adoption is moving upward. Regarding workflow within the pharmacy — there is essentially nothing to lose from making the switch from a paper process to ePA. With the aforementioned benefits, including enhanced productivity and increased revenue from recapturing prescriptions that could have been abandoned initially, pharmacies stand to gain considerably by implementing ePA.
All metrics and references from this article were acquired from the ePA National Adoption Scorecard, which remains an incredible resource for all information related to an electronic solution and its impact on the industry. For information, visit epascorecard.covermymeds.com.
Perry Lewis, Vice President of Industry Relations for CoverMyMeds, has more than 30 years’ experience managing relationships in the PBM, independent and chain-pharmacy environment and advocating for the needs of the patient. He is actively involved in state and federal healthcare advocacy initiatives, a frequent speaker at industry events and is the current chair of the NCPDP.