The complexities inherent in specialty therapies extend to their prior authorization (PA) process. Payers have stiff requirements before starting these high-cost therapies, and specifications regarding dispensation and administration further complicate matters. Given the potentially life-threatening nature of specialty conditions, it’s vital that the specialty PA process is as smooth and efficient as possible.
Related: How to stay ahead of a rapidly evolving utilization management landscape
Improving patient and provider experiences
A good specialty pharmacy proactively leverages technology to help simplify processes and enhance transparency. Meeting patients where they are—simplifying prescription refills through web and texting platforms and AI-enabled processes, and streamlining copay assistance updates—is the best way to improve their experience.
AI can be a valuable tool for improving the efficiency of PA processes. According to Evernorth’s 2024 Health Care in Focus Report:
- 91% of employers and 95% of health plan leaders say they are comfortable with AI use in health care
- 98% of health plan leaders agree AI could be helpful in assisting providers in note-taking and inputting electronic medical records
- 94% of health plan leaders believe AI could be helpful in reviewing PA requests
AI-enabled processes and digital solutions
AI and other digital solutions can help create more efficiency across the PA process. Digital tools provide visibility into the PA status and prescriber action items, and help obtain necessary clinical data from electronic medical records, avoiding delays caused by extraneous contacts.
Technology such as electronic prior authorizations (ePAs) can cut down on the time and effort required by traditional phoned or faxed PAs. Notably, 75% of faxed or phoned PAs take longer than one day to approve.1
iAssist, Accredo’s online e-prescribing and e-enrollment tool, helps coach providers through the referral process. This includes checking the coverage and potential cost of prescriptions, and giving providers the tools to complete the PA workflow by the time the prescription reaches the pharmacy.
MyAccredoPatients (MAP) allows providers to access patient information, along with anything that’s needed to help move the prescription along. It provides iAlerts if actions are required, and PAs, clinical information and more can be uploaded and tracked as the prescription progresses.
When providers or payers do run into complications, enhanced chat capabilities and customer relationship management tools can help expedite requests to keep things moving smoothly. The Accredo Client Portal is another digital tool that clients and payers can use to access utilization management data, streamlining service for their members.
Digital pilot programs show progress and potential
Accredo has begun piloting certain digital tools and models to modernize the PA process and ensure patients receive the care they need without taking any needless shortcuts.
Smart Coverage Review (SCR) streamlines the PA process using clinical data—instead of relying on physicians to provide answers to PA questions, Accredo pulls data from a variety of sources to automatically answer questions once a PA is started.
If all questions can be auto-answered, an approval can be made without additional physician engagement. If only a subset of questions can be auto-answered, then Accredo electronically sends the rest to the physician or is able to reduce the handling time on the phone.
In 2022, Express Scripts:
- Answered 3 million questions as part of 2.4 million cases via SCR logic
- Auto-decisioned approximately 10% of cases (over 251,000) via SCR
- Achieved a 20% reduction in PA questions a physician had to answer (in criteria implemented)
Today, 45% of all Express Scripts standard criteria have some SCR tech embedded.
Advanced predictive models can also assess all available clinical information before engaging a provider to estimate the likelihood of approval. Plans can then set a probability threshold and only engage the provider for cases that don’t meet the threshold, while auto-approving those that do.
A Cigna pilot focused on patients with rheumatoid arthritis and inflammatory conditions showed:
- 58% of patients were auto-approved
- 0% of patients approved should have been denied
- Overall workload was cut down to 40%
Accredo’s vision for the future of specialty prior authorization
Accredo is well-positioned to meet the challenges and opportunities presented by the future of specialty PA.
70% of our specialty providers use MAP, giving them:
- Visibility into PA expiration dates and notifications when PAs expire
- The ability to launch ePAs
- Access to document uploading can help communicate PA approvals as well as diagnosis and clinical information
65% of our patients are enrolled in one of our digital communication channels, which can:
- Provide real-time visibility of the status of an order and help avoid unnecessary phone calls to the pharmacy
- Display PA statuses for members to reference
- Notify patients if there are any delays with their order, including as a result of unresolved PA requests
The ultimate goal is to ensure the right patient receives the right drug. Accredo is fully equipped to help prescribers do just that. We’re doing this by continuously learning from our tools and optimizing them for maximum simplicity and transparency.
1 Accredo pharmacy data, 2022-2023.
