What’s all the fuss about prior authorizations: FAQ

Over the past few years, prior authorizations (PAs) have been in the headlines, examined by Federal and state governments, and hotly debated in the industry. Here’s the background:

  1. What is a prior authorization? Prior authorizations are a methodology used by health plans aimed at protecting members from unsafe and unnecessary procedures and prescriptions. Along with ensuring members are receiving appropriate therapies, prior authorizations also help reduce waste in healthcare.
  1. Why are they so frustrating? The vast majority of prior authorizations are conducted manually–requiring emails, phone calls, and faxes between providers, pharmacists, and plans. This back and forth is time-consuming and can result in delays to patient care.
  1. What can be done to make it better? Like many issues in healthcare, prior authorizations could be vastly improved with modern technology. This would make it easier to exchange data, understand the information required, and get the status of a PA–significantly reducing burdens on staff. It would also help to speed up the approval process, making it easier for members to get their medications.
  1. Who is working on fixing this process? CMS has proposed a new rule decrease the burdens associated with prior authorization and improve data sharing. Industry groups, like AHIP, are conducting research and making recommendations. Individual health plans are working to improve their own processes and add more automation. However, it is still very much a work in process.
  1. What does Abarca think? For prior authorizations to fulfill their purpose without creating needless burdens, we believe there is a better way. Along with automating the process, empowering pharmacists with the guidelines and tools they need to approve PAs on behalf of plans can significantly speed up this process, without compromising safety. Also, implementing real-time benefit checks can give providers more information at the point of care, allowing them to find clinically appropriate alternatives to medications that may require PAs.

We are currently developing ways to streamline and accelerate PAs for the millions of members we serve. Stay tuned for more details.

Francina Bonnelly, PharmD, Biomedical Engineer, Director, Clinical Products and Services at Abarca.

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