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Myndshft Blog

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October 11, 2023

The Anatomy of Effective Pharma Prior Authorization Software: Key Features

by Susan Lawson-Dawson | Healthcare Technology, Prior Authorization

Prior authorization for pharmaceuticals is a critical yet often complex and time-consuming process. Healthcare providers and pharmacists face off against a maze of requirements that differ from one pharmacy benefit manager (PBM) or payer to another. This can not only delay patient treatment but also piles on administrative overhead. As a result, choosing the right pharma prior authorization helps you optimize performance to reduce operational expenses while enhancing patient care. Here’s what you need to know. 

Pharma prior auth more prevalent than ever

Specialty medications increasingly capture a larger slice of drug spending in the US. These complex drugs often treat serious conditions like cancer, autoimmune diseases, and rare disorders. They typically require unique methods of administration such as nebulizers, injections, or infusions. These aren’t just pills you can pick up at any pharmacy and take with a glass of water. What’s fueling the rise in specialty medications? 

First, and foremost, Amerians are getting older. The number of Americans ages 65+ will hit 80 million by 2040. As the population ages, the need for specialty medicines will only grow. Older adults generally have a higher prevalence of chronic and complex medical conditions, many of which may require specialty medications for treatment.  

In addition, exciting advancements in biotechnology, genomics, and personalized medicine are enabling the development of highly specialized treatments that target specific mechanisms of disease. Unlike traditional medications that may have a broader application, these specialty medications are often designed for a narrower patient population, sometimes even targeting individual genetic markers. This precision often results in better outcomes, but it also comes at a higher cost of research and development, which is then reflected in the drug’s market price.

Unfortunately, as Dr. Peter McAllister writes in Practical Neurology, any enthusiasm providers feel at the potential of new pharmaceutical treatments is dampened by a universal thought, “Great! All these new drugs will need prior authorization, and my staff is overwhelmed as it is.”  That’s where intelligent prior authorization automation comes in. 

Providers still lagging on automated prior authorizations

A decade ago, the CAQH Index was established to track progress across the medical industry in automating administrative processes. The 2022 CAQH Index noted that “Adoption of electronic prior authorizations quadrupled (up 21 percentage points) since 2014.” In addition, the report found that “Increased automation and streamlined processes implemented so far have reduced the cost of our healthcare system by $187 billion annually.” 

Despite progress, however, the CAQH Index highlighted ongoing hurdles. For example, prior auth volume increased 61% in 2022 due to a lifting of prior auth restrictions established during the COVID-19 pandemic. Unfortunately, staffing levels haven’t rebounded as quickly, which only adds to the administrative burden.  As a result, time associated with manual prior authorization remains the highest among studied transactions. 

In fact, only 29% of providers have adopted fully electronic prior authorization. At the other end of the adoption spectrum, 33% of providers still rely on a fully manual process. The rest fall somewhere between manual and electronic, relying on a mix of  web portals, phone calls and faxes. 

Pharma prior authorization software handles the heavy lifting

Imagine a world where automated prior authorization software connects in real-time to all Pharmacy Benefit Managers (PBMs). It sounds like a utopia, but it exists today. Information flows effortlessly. Delays and preventable denials drop off.  What key features should you look for? 

End-to-end automation to speed the process

You can accomplish benefits eligibility and verification in a separate solution, but why would you want to if your prior authorization software can handle it all?  With an automated solution, you enter minimal data to start the process and the software takes over, moving you from benefits verification to prior authorization requirements determination, submission and monitoring—all in one place. It delivers  an astounding 70% reduction in manual effort, freeing up your time and resources for more valuable tasks—like actual patient care.

Pre-checking of submissions to eliminate preventable errors

Double data entry, mismatched information, lost forms—mistakes like these can cause delays and denials. Now, you can say goodbye to endless claims rework. Because prior authorization software identifies the correct form, submission criteria, and payer’s preferred submission method, payers receive prior authorization requests that have the right information. Not too much (which can lead to slower payer processing or denials) and not too little (which will also lead to denials). Instead, the software delivers requests that are “just right”—and that’s not a fairy tale. Prior authorization software enables efficient, accurate submissions that reduces claims rework by 90%. 

Lightning-fast transactions so patients get the prescriptions needed, sooner

The clock is always ticking, and it’s even more apparent when you’re providing care for patients with serious conditions like cancer or rare diseases. Prior authorization software slashes transaction time by 90%. By reducing delays, you help ensure better health outcomes for your patients.   

Easy tracking of prior authorization requests

With a centralized dashboard, you can keep track of all your prior authorization requests in real-time. No more frantic searching, no more endless phone calls to payers. It’s peace of mind, simplified. The days of sticky notes and spreadsheet chaos are over. 

Best-in-class security standards

Navigating the minefield of healthcare data security can be daunting. You should look for a prior authorization software provider that is HITRUST CSFⓇ r2 certified. It’s not just a badge; it’s a promise that your patient information is managed with utmost security and integrity.

Time is money; save both!

As Dr. McAllister said, “The extra PA red tape is one of a mounting number of ‘modern medicine’ irritants contributing to widespread physician burnout.”  

With prior authorization software, you can address burnout while also realizing cost advantages. Tasks that used to eat up over 30 minutes of your time can now be completed in under 5 minutes with prior authorization software. That’s not just a small tweak; it’s a game-changer.

Ready to transform your approach to prior authorizations and elevate your healthcare administration game? With intelligent, efficient, and secure prior authorization software, the future looks brighter—and healthier—than ever. Investing in the right pharma prior authorization software can significantly streamline your operations, ensure compliance, and elevate the level of patient care you provide.

Get started today.  Connect with Myndshft to learn more.