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The Bad and the Ugly of Prior Authorization and How Technology Will Fix It

Posted on May 16, 2018 I Written By

The following is a guest blog post by Karen Tirozzi, VP of Solutions, ZappRx.

Specialty drugs, which are usually defined by their complex instructions, special handling requirements or delivery mechanisms, are typically priced much higher than traditional drugs and cost more than the average American family’s salary. These medications are priced higher for a variety of reasons such as manufacturing costs, smaller patient populations and patient services like IV administration or at-home care required to support patients who will take these medicines.

Due to the costly nature of these treatments, payers insist on a comprehensive prior authorization (PA) process to ensure qualified patients are receiving the medications they need. The PA process involves cumbersome paperwork and fax machines and are a huge burden to physician’s and their staff. Physicians have even resorted to hiring extra, dedicated staff just to process these prescriptions as nurses, NP’s, PA’s and medical assistants tend to fall victim to the prior authorization nightmare. According to a recent study, it is estimated that $85,276 was spent on personnel costs to address billing and insurance issues associated with prior authorization, which is approximately 10 percent of practice revenue.

To put just how inefficient the PA process into perspective, a recent AMA survey of 1,000 physicians providing 20 or more hours of care a week, showed that doctors receive an average of 37 PA requests a week, which took an average of 16.4 hours to process. Extrapolate 16.4 hours a week over a year and clinicians are spending around 41% of their time annually doing paperwork, making calls and or sending faxes just to navigate PA and get medications to their patients. It includes enrollment forms and signatures from the patient, which can be done while the patient is in the office, however, it’s often done through mail, which slows down the process even more. Providers also have trouble ensuring they have the right forms for the insurer’s preferred specialty pharmacy, as sending to the wrong pharmacy also causes delays. Providers are tangled in faxes and phone calls for weeks on end so that all parties have all the information they need to approve just one prescription. In 2018, how is it that the medical community still heavily relies on fax machines to process information and deliver life-saving drugs to patients.

A Brighter Future

Digitizing the entire prior authorization process will significantly reduce the administrative burden on clinicians and get patients their medications in a much more streamlined manner. Healthcare providers should be able to, in one place, order a specialty prescription, see the paperwork and signatures needed and follow its progress until it reaches the patient’s hands. The healthcare industry needs to start utilizing the technology available today to streamline workflows and decrease operational expenses, which in turn, can help save patients’ lives.

By embracing technology, clinicians can also leverage the rich data sets generated to better understand their patients’ needs, trends within the space they’re treating and ultimately, improve patient care. Data can also be used by pharmacies to understand how their medications are trending within the market and catch any snags that may cause delays. The potential for pharma companies to use this level of information to provide insights and improve products in real-time is invaluable.

Let’s take the next step

Inherently risk adverse and with siloed stakeholders, healthcare must begin taking steps toward change. With what the space has at its disposal from a next-generation technology standpoint, there is no excuse to remain chained to the fax machine.

The good news? Providers, pharmacists and biopharma have options to improve this cumbersome process today. Forward thinking innovators are beginning to break down silos and uncover new methods with technology to streamline the prior authorization process and get patients their specialty medications in days, not weeks.

About Karen Tirozzi
ZappRx Vice President, Solutions, Karen Tirozzi, leads a fast growing team that is focused on transforming the specialty pharmaceutical prescribing process. With a focus on client success, Karen and her team are innovating technologies to automate traditionally manual and cumbersome processes in an effort to save clinicians time and resources, and deliver lifesaving drugs to patients in a timely manner.  Having spent more than 15 years in the industry, Karen’s unique background in HIT and clinical social work serve as the basis for her ability to deliver successful programs in highly disruptive healthcare services and IT companies.

5 Stages of Provider Dissatisfaction and Happiness

Posted on June 21, 2017 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

A couple weeks ago I posted an infographic on the 5 stages of patient frustration and the 5 stages of patient satisfaction. This week SCI Solutions came out with a new infographic which looks at the 5 stages of provider dissatisfaction and the 5 stages of provider happiness.

It was interesting that the infographic focused so much on the pains of prior auths. I agree that this is extremely painful for doctors and definitely leads to a lot of dissatisfaction. However, I’m surprised that they didn’t include the EHR and other regulations related to the EHR in their list of provider dissatisfaction. I’m sure EHR and prior auths would fight a good fight as to which is more annoying to doctors.

As for the provider satisfaction, the infographic focused so much on easy access to the right information. I agree that’s a valuable thing, but the most valuable thing is doctors getting quality time that helps their patients. We need to facilitate more of that in healthcare.