How Advocate Aurora Health Streamlined Prior Authorizations

Automating the prior authorization process

Despite the evolution of healthcare from paper documents and mail to EHRs, clinical decision support systems, and other innovative solutions, 88 percent of prior authorizations are still either partially or completely manual, the Council for Affordable Quality Healthcare (CAQH) recently reported.

Frustrated with using phones and fax machines to manage the increasing burden of prior authorizations, Hardin turned to Advocate Aurora Health’s EHR system.

“About three and a half to four years back, we realized prior authorizations were a problem and we wanted to see what we could do to try to speed up the process and take advantage of the EHR system that we had at the time,” he explained.

“We thought, ‘What functions are available once our pharmacy does go live on the system? What do we have available to us?’ One of the functions we saw was the electronic prior authorization.”

From there, Hardin assessed the market for technology solutions that could work with the EHR’s electronic prior authorization capabilities. After a solutions analysis, the health system decided to implement an automated prior authorization solution from Surescripts.

With the solution, providers trigger an automated prior authorization workflow by prescribing a medication or service that requires payer approval prior to delivery.

“The solution has a lot of the pharmacy benefits management information already built in, so now the typical prior authorization process happens automatically,” Hardin elaborated. “The clinic staff never need to touch about 80 to 85 percent of authorizations for our patients.”

“The handshake with the insurance company is done through the pharmacy benefit manager,” he stressed.

While the solution enabled Advocate Aurora Health to automate prior authorizations for the majority of requests, the health system was stuck trying to streamline the process for the remaining 15 to 20 percent.

Not all pharmacy benefit managers allow electronic prior authorization communication and payers generally want more on patients who require expensive medications to treat unusual conditions, Hardin explained. Additionally, the solution does not always have the most up-to-date pharmacy benefit information, which payers regularly modify to reflect how providers are practicing medicine.

In these cases, clinic staff and providers had to step in to handle prior authorizations.

However, Hardin and his team dedicated themselves to streamlining the process for all prior authorizations. Out of their dedication came the centralized authorization team.

Centralizing prior authorizations

Made up primarily of pharmacy technicians, the centralized authorization team at Advocate Aurora Health removes the burden of prior authorizations off the plates of clinic staff and providers.

Clinic staff still receive a notification when providers trigger a prior authorization in the EHR that the solution cannot fully process electronically. But staff can now send the prior authorization to the centralized authorization team to complete.

With access to the electronic medical record, the team is able to gather the information payers need to complete the prior authorization. They are also able to complete prior authorizations anywhere as long as members have access to a phone and a computer.

With the support of the centralized authorization team, clinic staff and providers are free to focus on other important tasks, like improving patient care.

“The clinics no longer have to call or interact with the pharmacy benefit manager, the insurance companies, et cetera,” Hardin highlighted. “Our physicians are also almost never involved in prior authorizations anymore.”

Providers at Advocate Aurora Health are satisfied with the health system’s strategy for streamlining prior authorizations. Since implementing the strategy, clinic workflows are now more efficient, and coincidentally, the health system has noticed a consistent reduction in clinic overtime in every one of its markets.

But the most important improvement to come out of the prior authorization strategy was the fact that more patients were filling their prescriptions and adhering to their treatment plans.

“In general, patients are filling their prescriptions. But there was about a ten to 15 percent increase in patients getting their meds on the day that they were prescribed,” Hardin emphasized.

Prior authorization reform still has some ways to go. But the burdens associated with prior authorizations are unlikely to subside as the industry transitions to value-based care.

To support staff and providers while ensuring authorizations do not impact patient care, providers can follow in the footsteps of industry leaders like Advocate Aurora Health by using technology and people to efficiently and effectively improve the process.