Section 07: Payer

Currently, 96 percent of payers are committed to an ePA solution. By communicating the preferred electronic method for processing PA requests and implementing operational changes, payers can influence provider adoption of ePA solutions.

Learn about Payer influence on ePA Adoption
Payer header image

Payer Influence

Although provider adoption of ePA solutions averages at 47.5 percent according to payers representing 96 percent of market share,40 individual payers have demonstrated provider adoption as high as 87 percent following ePA integration.41

This success was realized by a regional health plan that enabled auto-determination for ePA and implemented operational changes directing providers to the electronic channel versus traditional methods of phone or fax (i.e. explicitly directing providers to use ePA).41

In contrast, the top five PBMs by market share demonstrate provider adoption of ePA at 51 percent and may benefit from the provider adoption tactics used by successful regional health plans.41

Payers providing coverage for commercially insured patients typically see greater provider adoption than programs servicing patients covered by government programs, which could suggest that providers do not perceive ePA as a solution for Medicare and Medicaid and/or that Medicare and Medicaid payers do not quickly integrate ePA solutions. For instance, despite 87 percent provider adoption overall in the above example, electronic submission for PA requests for Medicare Part D drugs lagged behind by 17 percent.41

Some payers have achieved 87 percent provider adoption of ePA, relative to the 47.5 percent industry average.41

Communication and operational changes from payers on ePA are key drivers for provider adoption. Such changes include transparency around availability limitations, indication that ePA will work for Medicare and Medicaid and the potential for auto-determinations. Payers can also make a difference through fax back responses encouraging providers to use ePA for completing requests.

Indicating a payer is live with ePA does not mean all medications or plans—in the case of a PBM—use ePA functionality. The majority of payers initially activate ePA for a select number of medications or plans that they service while they work toward electronic incorporation of all criteria, which differs by plan and medication.

As more providers complete PA requests electronically, payers can expect to extract the most benefit from ePA solutions, including:

Time and cost savings from reduction in phone calls and faxes — reduces call center volume by 22 percent in some cases42
Decrease in time to therapy to improve member satisfaction and patient outcomes — 35 percent shorter turnaround times for PA determinations on average9
Increased medication adherence to limit unnecessary hospitalizations — 80 percent higher dispense rate relative to fax in some cases8
Complete and accurate initial submission of PA requests — 30 percent reduction in PA reviews in some cases43
Possible real-time determinations based on preset, payer-specific criteria — 27 percent increase in auto-determinations in some cases44
Increased perception of access to medications — patients are 3 percent more likely to pick-up their prescriptions when PA request are completed electronically9

Payer Availability

Percentage of the payer market, representing the majority of market share by prescription volume,* committed to an ePA solution.41

* The remaining 4 percent of market share represents prescription volume from many smaller health plans.

Payer Committed Available
Argus Health Systems
CVS Health
Envolve Pharmacy Solutions
Express Scripts
Magellan Rx
Mayo Clinic Health Solutions
Moda Health Plan
Prime Therapeutics

Vendor Assessment

It is important to understand how an ePA vendor will accomplish key goals needed to successfully complete PA requests. The wrong solution could create administrative waste, cause confusion between stakeholders (payer; pharmacy; provider) and hinder a patient getting the medication they need to be healthy.

How many live integrations does the solution have with payers? Is there an option for submitting forms for health plans that do not offer an electronic solution?

It is important that PA requests can be submitted to any plan in the same ePA solution and workflow. Ideally, the ePA vendor will have a direct, electronic connection with payers representing the vast majority of prescription volume, and the ability to facilitate auto-determinations.

It is equally important to facilitate an electronic workflow for providers that connects with health plans who are not ePA enabled. While the majority of the payer market is working toward ePA availability, there remain lines of business, regional plans and Medicaid and Medicare Part D plans that are not yet live with ePA functionality.

Is auto-determination functionality available through the ePA vendor?

Auto-determination functionality enables payers to set criteria for PA determinations to eliminate manual review. The result is a more efficient process for payers and faster determinations for providers. Electronic prior authorization vendors who offer this functionality should allow full customization of the criteria used to make an auto-determination.

Does the ePA vendor technology support APIs?

The technology for ePA solutions will grow and change with the industry; therefore, API support makes it easier for technology teams at EHR, payer and pharmacy systems to quickly implement new and optimized ePA solutions. Documented, standards-based ePA APIs will be a key to driving adoption in the market.

Key Takeaway

Key Takeaway

As nearly the entire market share of payers is committed to ePA and bringing additional lines of business onto electronic solutions, increasing provider adoption is a primary challenge for returning the most on investment. Enhancing provider access through extending ePA to all lines of business, increasing the usage of auto-determination functionalities to help reduce turnaround times and insisting that providers use ePA will be key to promoting adoption and supporting patient care.