icon representing ePA

01 ― About ePA

The industry continues to take note of the importance of an electronic prior authorization (ePA) solution and how it benefits all stakeholders. More states are adopting ePA language, more legislation is being proposed and electronic health record (EHR) systems are moving the needle forward on enabling PA.

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02 - Impact

While the market continues to grow and evolve, a natural focus is beginning to shift to more strategic and granular approaches to ePA to meet market need; for example, how can ePA be of use for specialty medications?

What other technology solutions are there to solve problems such as real-time prescription benefit check during the E-Prescribing process? It is important for the patient and health care IT, as an industry, to tactically execute on solutions to solve existing problems, and to be deliberate in advancing future solutions.

NCPDP Transactions

Electronic prior authorization is the automated process of exchanging patient health and medication information required to help the patient’s prescription coverage plan make a coverage determination.

Today, many prior authorization requests are completed through a manual process that involves phone calls and faxes between the pharmacy, provider and health plan. This is an inefficient, time-consuming process that leads to the patient abandoning the prescription 36% of the time.1

Electronic prior authorization automates this process by allowing the provider to initiate the ePA prospectively within their E-Prescribing workflow. The most successful ePA strategies also connect the pharmacy to initiate an ePA that was missed at the point of prescribing, and allow the provider to complete a pharmacy-initiated PA electronically in their EHR or a designated ePA web portal.

The ePA process involves a four-part transaction established in the National Council for Prescription Drug Programs (NCPDP) SCRIPT Standard that enables patient and drug-specific prior authorization (PA) criteria and a real-time approval process.

Infographic depicting the ePA process

E-Prescribing vs. ePA

As ePA capabilities and adoption grow, particularly in the EHR space, there is often 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.

Illustration depicting E-Prescribing

E-Prescribing

Electronic prescribing allows providers to write and submit prescriptions to pharmacies electronically through an EHR, rather than 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.

Illustration depicting ePA

ePA

Electronic prior authorization occurs after a prescription is prescribed when a pharmacist or provider is notified that the patient’s health plan requires PA to ensure coverage. Electronic prior authorization transforms the existing paper PA process into a real-time exchange of information that determines insurance coverage for a prescribed medication.

Illustration depicting eFax

eFax

While eFax is not directly connected to the payer, it allows providers to submit a PA request using the same electronic workflow, regardless of the ePA capabilities of the payer. The pharmacy or provider may still initiate the PA and complete it electronically. It is then delivered to the payer via fax for processing.

Key Takeaway

Key Takeaway

The industry continues to make great strides toward all stakeholders being on board with an electronic solution for PA. As progress is made, the vision now shifts to other areas of improvement in the industry that can ultimately benefit patients, such as solutions for real-time prescription benefit and specialty medications.