The industry has seen great strides in the utilization of electronic prior authorization (ePA), as illustrated by parts of the industry being more than 70 percent committed to implementing an ePA solution1. As ePA capabilities and adoption grow, particularly in the electronic health records (EHR) space, we often encounter confusion as to the difference between ePA and electronic prescribing (E-Prescribing). A common misconception is that if a provider is E-Prescribing, they are also completing PA requests electronically.
While E-Prescribing and ePA will ideally occur in the same workflow within an EHR, they are not the same service. At a high level, E-Prescribing allows a prescriber to write and submit a prescription for the patient to receive. Electronic prior authorization handles additional requirements for the prescription dictated by the patient’s insurance plan to approve coverage.
Let’s examine ePA and E-Prescribing more closely to outline the key differences industry participants need to understand.
Electronic prescribing allows prescribers to write and submit prescriptions to pharmacies electronically through an EHR instead of handwriting or calling it in to the pharmacy. It is beneficial to the patient in that they don’t have to worry about bringing a paper copy to the pharmacy because the doctor submitted it electronically. In many cases, as a result of E-Prescribing, the prescription is ready for the patient to pick up the moment they arrive at the pharmacy. E-Prescribing can only be completed through an EHR.
Electronic prior authorization happens after a prescription is E-Prescribed when a pharmacist or prescriber is notified that the patient’s health plan requires prior authorization to ensure coverage for a specific medication. Electronic prior authorization transforms the existing paper PA process into a real-time exchange of information that determines insurance coverage for a prescribed medication. This electronic process, following the NCPDP SCRIPT Standard2, provides decision support to the physician so they can best treat the patient, and positively impacts medication adherence by preventing the time consuming back and forth of the PA process that leads to provider frustration and prescription abandonment. The ePA process can be started in a pharmacy system, EHR or web portal.
Electronic prior authorization is a 4-part process3 that can be initiated by a provider (prospectively) or a pharmacist (retrospectively).
Prospective ePA: This occurs when a prescriber initiates the PA before a rejection occurs at the pharmacy. It is possible to proactively begin a PA request at the point of prescribing, directly within the EHR system. If the EHR and health system have ePA enabled, the doctor is alerted that the prescribed medication for a particular patient requires PA. By clicking a couple buttons in their EHR system, the prescriber initiates the ePA process with the insurance plan and can receive a real-time determination. The prospective process can also occur in an all-payer web portal, like CoverMyMeds. Today, less than 30 percent of PA requests occur prospectively4 due to the change in workflow from the traditional, retrospective process.
Retrospective: The more common process, retrospective PA occurs when a pharmacy is alerted that PA is needed when they bill insurance for the medication. The pharmacist can initiate the PA directly in their pharmacy system, which triggers a notification to the prescriber. The prescriber can then complete the PA request in their ePA-integrated EHR, if functionality allows, or in an all-payer web portal. Either option provides the same outcome: the prescriber completes the PA and electronically submits it to the insurance plan for a determination. When an outcome is received it is electronically delivered to the prescriber and the pharmacy.
Electronic prior authorization is the ideal path for prescribers, pharmacists and payers to use to reduce administrative waste and increase speed to therapy and medication adherence.
Today, the majority of ePA transactions occur in a web portal, predominately in CoverMyMeds, as the industry works toward integrated solutions at the point of prescribing.
While most large payers have adopted ePA, some are still in the process of implementing it across business lines. Additionally, some smaller plans have not yet adopted an electronic solution. As a result, a partial electronic solution called eFax may be used to maintain a consistent provider workflow.
Electronic fax is not directly connected to the payer, but still allows providers to submit a PA electronically using the same workflow they use for ePA requests. The pharmacy or provider may still initiate the PA and complete it electronically. It is then delivered to the payer via fax for processing. The benefit is maintaining the electronic workflow for pharmacists and providers, despite the payer limitation to how they receive the request. With eFax, the provider and pharmacist still save time as compared to the arduous paper process, which fuels industry adoption of completing all PA requests electronically. A survey completed by CoverMyMeds indicates that providers using eFax can complete PA requests in as little as 3-5 minutes, as compared to the estimated 15-20 minutes required for a paper PA request5.
Until 100% of payers adopt ePA, an eFax solution is beneficial to establishing a partially electronic process.
For payers, EHRs and health systems selecting an ePA solution it’s important to remember the differences between E-Prescribing and ePA to fully evaluate the capabilities of a partner. To achieve the full benefits of an electronic process today, industry participants should evaluate solutions that offer integrated ePA and portal capabilities, as well as eFax as a safety net for requests that cannot be completed in the standard ePA process.
CoverMyMeds is engaged at a federal and state level to help educate decision makers on the ePA process so they can make informed regulatory decisions.
For questions or additional information reach out to Kim Diehl-Boyd of our Government Affairs team at firstname.lastname@example.org.