Proof that Electronic Prior Authorization is Exactly What You’ve Been Looking For

May 2023

Prior authorization (or pre-authorization) is a process by which healthcare providers confirm that a drug, service, healthcare action, or piece of equipment is medically necessary for a patient. Confirmation of medical necessity helps determine the amount of coverage the patient will receive for a specific form of treatment or care from a health insurance provider.

It’s no secret that the PA process has become a point of contention for both providers and patients. For both parties, there is often frustration due to the turtle’s pace of approvals or lack of. The risk is a delay in much-needed medications or medically necessary equipment and procedures getting approved and delivered to the patient. The actions recommended by a provider are all part of the care plan to stabilize or improve a patient’s condition, and the delays caused by prior authorization can have detrimental impacts on that plan.

The burden being put on providers is significant. In 2017, a survey published by the American Medical Association reported that physicians and their staff were completing 37 prior authorizations each week, with estimates that average as high as 16.4 hours per week being spent on administrative tasks related to Prior Authorizations. Even if part of this time could be redistributed to patient appointments, the results could be shorter wait times to see your doctor and more timely patient communication.

History of Prior Authorization

PA began as a utilization review process developed after the introduction of what is now Medicare and Medicaid. As patient populations at hospitals increased, there was a need to determine where inpatient care was medically necessary to avoid overfilling hospital capacity. Utilization reviews were originally completed in the hospital by other practitioners, but over time expanded and were initiated by insurance companies, transforming into the current model.

Before the age of digitizing medical records and healthcare operating systems, prior authorizations were completed through snail mail letters, fax, or phone calls, causing unreasonably long wait times between requests and responses. There was also a higher likelihood of requests being lost or denied for clerical errors like misspelling part of a patient’s name, smudging on the form, or general illegibility. Providers would have to check with their patient’s insurance manually to see if PA was required. After confirmation, they would submit a request to the payer to begin the process.

How does prior authorization work?

Today, PAs can be initiated by any part of the patient care loop: provider, payer, pharmacy, or patient. In cases where a patient may be aware that a form of treatment requires prior authorization, they can work with their provider to begin the process sooner.

Because forms do not have a federal standard and vary by state, they may differ in the amount of information or relevant details asked for in the form. To make matters more complicated, different medications or insurance may require different amounts of information. The process is completed by the provider using patient information to determine the best form of care and submitted either over the phone, by mail, fax, or electronically.

Information Required in PA Forms:

• Patient demographic information
• Diagnosis
• Previous treatments used
• Relevant lab work

Accelerating the Process: Electronic Prior Authorization

Electronic prior authorization (ePA) is the newest iteration of the approval process in the healthcare system. The use of ePA is increasing across healthcare, with 44% of authorizations processed electronically in 2022 (Surescripts 2022 National Progress Report).

Electronic prior authorization shortens wait times, allowing providers to submit, respond, and appeal prior authorization requests faster. As you would expect, going digital speeds up the process, with the average time to receive a response to ePA requests averaging 3 minutes and 54 seconds in 2022.

Why ePA is Gaining Popularity

Reduces Complexity:

Electronic filing decreases system complexity, therefore, reduces stress for providers, especially in the case of telehealth or cross-state practices that may need to utilize multiple forms depending on an individual patient, pharmacy, or health insurance payor.

Decreases Errors:

It also helps streamline the process and decreases errors. Integrating a prior authorization solution with existing EMRs helps pull relevant care information into the request automatically, decreasing time spent on repetitive information.

Allows for Automation:

Integration with EMRs can also factor in Real Time Prescription Benefits (RTPB) information, which lets providers know if a treatment plan they’ve selected requires prior authorization, suggests alternatives that don’t require it, and the out-of-pocket cost for those alternatives. This means that the PA process can begin at the point of care, decreasing wait times for patients to receive their treatment and alleviate their symptoms.

Added IT Security of Protected Health Information or PHI

Completing a PA electronically is also more secure and removes many risk factors associated with mailing or faxing prior authorization request forms. In a time where a data breach could be disastrous to the future of your healthcare organization, added protections should be taken advantage of.

How does DoseSpot help?

DoseSpot’s EMR or EHR integrations help to speed things up by allowing you to automate the prior authorization process, decreasing the time spent switching between applications to find all relevant pieces of patient data to send alongside a request.

We also have RTPB integrations with companies like Surescripts to provide coverage alternatives and flag prescriptions that will need PA, allowing more work to be done at the point of care to prevent stress or delays in treatment for patients.

DoseSpot offers electronic prior authorization services for providers who both use DoseSpot’s prescribing app and those who integrate with our API, ensuring less time spent on prior authorization regardless of how you use the DoseSpot solution.

Lessening the Burden with ePA

The American Medical Association reported in their 2017 survey that 75% of provider respondents said the burden was “high” or “very high” for PA, and more than half defined average wait times for response as a day or longer. We know this problem has continued to grow as more medications and procedures require approvals than ever before.

Hours spent manually filling out forms and fighting with bureaucratic systems are one way to create barriers between a patient and the care they require. While electronic prior authorization is only one step in a movement seeking to reduce the administrative tasks from clinical teams, by adopting it, you can help providers spend more time speaking with their patients and getting to the root of their healthcare issues.  When clinical teams are less stressed, they deliver better and more empathetic care. Isn’t that what we are all looking for?

If you would like to learn more about DoseSpot’s electronic prior authorization solution or would like demo, please get in touch by completing the form below!