Widespread Electronic Prior Authorization Standards

Electronic prior authorization standards (ePA) are a great idea. They can streamline prior authorization workflow for physicians, shrink delays in patient care, and automate burdensome manual processes. Despite those benefits, professional medical associations and state legislators have had to force the issue for ePA to see any meaningful implementation. It has been like pushing a rock uphill for the past decade, but with the help of increasing legislation, the peak is in sight. Here is what you need to know about electronic prior authorization standards to make them work for your practice.

Issued years ago, the call for electronic prior authorization struggles on

Back in 2011, the American Medical Association (AMA) issued a white paper calling for standardization of the prior authorization process. At that time the association called for replacing manual prior authorization processes with automated ones that were “transparent, unambiguous” and conducted in real-time.

In 2014, an article in the trade newsletter HIMSSwire touted the promised of ePA saying that industry-wide adoption based on national standards held “the potential to streamline and improve the process for all stakeholders, improving process efficiencies and reducing time to treatment.” HIMSS dreamily said that ePA could “potentially result in fewer prior authorization requests because health care providers will have the coverage information they need when making a treatment decision.” It was a great vision, but little of that has come to fruition. The battle rages on.

In 2017 the AMA once again issued a Consensus Statement urging healthcare leaders and policymakers to act urgently to improve the prior authorization process that has become onerous for physicians. The statement encouraged “health care providers, health systems, health plans, and pharmacy benefit managers to accelerate the use of existing national standard transactions (National Council for Prescription Drug Programs [NCPDP]) for electronic prior authorization,” to speed up drug authorization approvals and improve medication adherence.

NCPDP standards are developed to streamline communication between prescriber and payer for the approval of pharmacy benefits for medications and supplies. The standards support:

  1. A method to convey a set of PA questions logically in any system and the answers returned reliably.
  2. Features to minimize what the prescriber is asked, based on earlier answers or data in their Electronic Health Record (EHR) system, thus reducing the amount of time a prescriber/or staff spend reviewing and responding to the PA questions.

The reasons that ePA streamlining standards are needed are painfully evident. According to the AMA:

  • On average, practices complete 37 prior authorizations per physician per week
  • Physicians and staff spend two full business days per week completing prior auths
  • 90 percent of physicians say prior authorizations can delay patient access to care

Today, states are picking up the ePA charge to move it forward

Increasingly, state legislatures are picking up the charge and passing legislation that requires insurers and vendors to integrate ePAs into their electronic medical record systems. States are cracking down on delays in prior authorizations to reduce delays in the delivery of care. For example, in Ohio, insurance plans must respond to prior authorization requests within 48 hours for urgent care requests and within 10 days for nonurgent care.

The AMA has drafted model legislation that sets the bar even higher for transparency and quick response from 3rd-party payers. It also addresses the fly that has long been in the ointment changes in 3rd-party payer policies. The AMA legislation requires that insurers give practices at least 60 days notice before putting ePA policy changes into effect.

Legislation regarding ePA varies according to state. In general, they address the issue in four different ways:

  1. ePA (NCPDP standard): calls for the use of an electronic method for submitting medication prior authorizations in compliance with the NCPDP script.
  2. Standard ePA (no standard): calls for the use of an electronic method for submitting medication PA but names no rules
  3. Standard form: Calls for the use of a global or standard form for medication PA approved by the states’ department of insurance
  4. Standard form and ePA: Calls for the use of a universal or standard form as well as the use of an electronic method for submitting medication PA.

To find out what standards have been passed in your state, covermymeds.com presents a comprehensive map.

The key to good ePA — compliance in 2018

As medical associations and state legislators fight to streamline prior authorization processes for physicians and require electronic prior authorization standards, physician practices won’t reap the benefits unless they comply with regulations. One study showed that many providers who use ePA for prescribing don’t always use the NCPDP ePA standard. That’s a problem. Make sure that your practice’s internal systems, including revenue cycle management, prior authorization and electronic medical records incorporate ePA standards into their protocols. Once the soldiers have successfully fought the battle, only widespread compliance with the standards will help them to win the war.

About the Author

Infinx Healthcare provides innovative and scalable payment lifecycle solutions for healthcare practices. Combining an intelligent, cloud-based platform driven by AI with our trained and certified coding and billing specialists, we help clients realize revenue, enabling them to shift focus from administrative details to billable patient care.

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