What are the best practices for streamlining prior authorization processes in utilization management?

In most instances the primary role of prior auth is cost savings. Criteria are generally based on clinical evidence. Cost of the intervention is usually the second criteria. Particularly in the case of pharmaceuticals, cost may be a factor that a provider can neither anticipate nor control, sometimes boiling down to contractural arrangements between manufacturers and payers. It isn't practical for individual providers to be able to track this. AI and clinical decision support within EHRs, ePAs, or other portals will be key in the future to being able to keep track of and apply differences, since widespread agreement among payers seems unlikely.

Providers have difficulty familiarizing themselves with each insurer’s requirements because they aren’t widely publicized. This leads to frustration from providers when they encounter UM after prescribing. By integrating ePA into the EMR, prescribers have the information at the point of prescription entry. This integration is not available through all PBMs, but should be something Payors should start requesting from their PBMs as this greatly simplifies the process.

In my experience, the agent who handles your contracting is a great person to start with regarding resources offered by a provider. This can be setting up portal access to resources from a health plan to determine if a prior authorization is necessary or guidelines.

To improve communication and efficiency, it is helpful to provide providers with a direct phone number to the UR department rather than directing them to the call center. This allows providers to quickly and easily connect with the UR department without wasting time navigating a phone tree or enduring long wait times.

In my past experience as a medical director for a managed care company, I would encourage providers to exercise their peer-to-peer discussion option. This is the most productive way to discuss a patient's needs if PA criteria do not strictly apply to the specific situation, or other factors apply. Medical Directors are usually physicians with an interest in patient care. Even as insurance company employees, they have an interest in the best outcomes for members. They just might not agree on the best way to get to those outcomes.

They should conduct genetic testing to determine the effectiveness of the medication on each patient based on the genetic information of each patient. This will help in a fast healing process.

Modern utilization management should not be viewed in a silo. It’s not about denial rates and turn around times. It’s about guiding your provider network to practice using evidence-based guidelines. Authorization requests should be viewed as a leading indicator for case or care management involvement. Out of network provider requests should be tracked for provider access issues. Authorization requests should also provide guidance for finance to adjust IBNR models. UM should not be viewed as a tool to manage MLR. Appropriate care provided to appropriate members in the appropriate location at the appropriate time is the ultimate goal for a health plan. How they individualize a member’s care plan and coordinate with the PCP is the key.

All providers and their Authorization Specialists AND all front-line personnel facilitating pre-authorizations NEED to know that there IS a federally mandated process for EXPEDITED REVIEW. When the turn-around time for an Authorization decision NEEDS to be extremely short, i.e. 24 hours due to critical need, PROVIDER requesting such pre-auth NEEDS to convey that keyword phrase & specifically request an "expedited review" ...LIKEWISE, the front-line Rep in UM NEEDS to know that such use of the phrase EXPEDITED REVIEW means they must identify the request as an EXPEDITED REVIEW request & the carrier must have an internal process for facilitating the process, essentially fast-tracking the review/decision process.