This Time of Year Sees a 54 Percent Increase in PA Requests. Are You Prepared?

 |  Brian Kolligian, Provider Solutions Consultant

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Historically, January and February bring a 54 percent increase in the number of prescriptions that require prior authorization (PA).1 The cause of this increase is threefold:

  • Changes in prescription coverage: Many health care plans are reviewed and updated at the beginning of the calendar year, including which medications are covered.
  • Formulary modifications: Formulary processes may also change as plans are reviewed, introducing new or updated requirements for PA, step-therapy programs, use of preferred drug lists and drug benefit caps.
  • Renewal requirements: Whether triggered by prescription renewal, formulary modification or some other factor, PA renewals tend to stack up during these two months.

The traditional, paper-based PA process can slow down offices and limit providers’ time with patients, especially when so many prescriptions require approval in a short period.

The PA Burden

While PA is a necessary part of securing the most medically appropriate treatments for patients, the traditional, paper-based model is a burden on providers and their staffs.

This strain shows little sign of improving—in fact, it may be worsening. Eighty-six percent of physicians in a recent American Medical Association (AMA) survey said that the administrative burden related to PA requests has risen in the last five years, and most of those respondents reported it has “increased significantly.”2

Today, medical practices spend an average of two business days each week per physician completing the necessary processes for PA requirements.2 To help cut down on provider time spent outside of patient care, one-third of practices employ staff members solely devoted to completing PA requests.2

For the practices that don’t have dedicated staff members, the providers themselves and their staffs often spend hours filling out forms and calling health plans to appeal PA requests. And this is not limited to PA requests for patients getting on a new medication: 79 percent of providers have repeated the PA process for medications that are part of a regular treatment regimen for a chronic condition.2

The average time a PA request takes to complete varies slightly, but typically takes a few days if submitted the traditional way through fax and phone calls. More than 60 percent of providers have been delayed at least one business day waiting for a PA approval. Additionally, 30 percent regularly wait more than three days, and 7 percent more than five days.2

With the PA process already delaying patient care in some instances, the window of seasonal increases in PA requests can entirely derail an office if you’re unprepared.

Preparing for “PA Season”

Preparation for this inordinately busy time of year could be the key to keeping yourself, your staff, and most importantly, your patients, happy. To maintain a reasonable workload and give as much time to patients as possible, consider the following tips:

  1. Utilize a free electronic prior authorization (ePA) platform. Many prior authorizations can be completed in seconds with an ePA tool. If your EHR or health system doesn’t have an ePA solution already integrated, you can sign up for a free CoverMyMeds account and submit PA requests through an ePA portal at no cost.
  2. Ensure office communication and operational procedures are functional. For example, check that every staffer involved in the PA submission process has access to the appropriate information, software and files to eliminate slowdowns.
  3. Be ready for renewals. The last thing you’ll want to worry about with an influx of new PA requests is an expired one you didn’t see coming. Stay ahead of renewals by assigning a staff member to track soon-to-expire PA approvals so you’re able to efficiently reinstate them. This process limits patient frustration by making prescription compliance easy and convenient.
  4. Discuss the possibility of a PA request slowdown with patients. It could soften the blow of a treatment delay if the patient is aware that you may need additional time to complete necessary paperwork. Encourage patients to call their pharmacy before arriving to ensure the medication is ready.
  5. Train your staff on excellent documentation habits. Not only should all PA documentation be correct, insurers are often likely to heed provider notes in documentation as opposed to reading pages of medical records. A PA request that includes a clarifying note within the chart about the therapies a patient has already tried could eliminate any ambiguity and make approvals more efficient.

With proper planning, your office should experience limited frustration in the height of ”PA season.” If you’d like to learn about the industry leaders who rely on ePA to enhance interoperability, view the 2018 ePA National Adoption Scorecard.

  1. Prepare for a Seasonal Increase in Prior Authorization Requests
  2. 2017 AMA Prior Authorization Physician Survey
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