Prior authorization is an important checkpoint helping patients access coverage for safe, effective care supported by the most up-to-date clinical guidelines. Reviews facilitated up front ensure providers and patients know if a service requested is covered prior to care delivery.
The process, however, can be inefficient, adding manual, time-consuming tasks to providers’ already heavy workloads. Burdensome wait times can also lead patients to abandon prescriptions at the pharmacy counter.
With an eye on improving such processes and the patient experience, Optum Rx and Surescripts, a health information network, partnered to develop Optum Rx PreCheck Prior Authorization – an innovative solution to help automate the prior authorization submission and approval process for select drugs, including GLP-1s for diabetes.
From hours to seconds
PreCheck Prior Authorization helps alleviate physician administrative burden and expedite prior authorization approvals – from 8.5 hours to under 30 seconds.1
For providers
The solution helps fully automate the process by retrieving targeted, relevant data from providers’ electronic medical record (EMR). It then pre-populates answers to clinical requirements, analyzes data and sends an automatic approval if all clinical criteria are met2. This allows providers to spend more time caring for patients.
For patients
Prior authorizations are automatically created, resulting in a median approval time of 29 seconds before the patient goes to the pharmacy for pick up. This eliminates frustration some patients may have when they arrive at the pharmacy to pick up their medication, only to learn their claim has been denied.
For pharmacies
Pharmacists may see decreased patient walk-away rates and reduced order cancellations and spend less time tracking down prior authorizations with providers.
Pilot program successes
In a pilot program with the Cleveland Clinic and another large health system earlier this year, Optum Rx and Surescripts helped to achieve a drastic reduction in prior authorization approval times.
Key takeaways from the program include:
- Shorter approval time, leading to faster prescription access for patients: With the previous manual process, health care organizations reported prior authorizations for GLP-1 medications took 15–20 minutes; automation dropped that time to a median of 29 seconds.
- Increase in automated approvals: For in-scope medications, 62% of approvals are now automated, leading to 25% of applicable prior authorization requests being automatically approved.
- Improvement in provider and patient experience: The patient path to therapy was expedited with an 88% reduction in appeals and a 68% reduction in denials caused by a lack of information.
- Decrease in physician abandonment rate: The percentage of requests for which physicians receive a question set for additional information but never complete it dropped from 31% to 25%.
- Improvement in efficiency: Automation improved administrative efficiency, giving providers more time to focus on patient care and clinical teams more time to address complex cases. It also saved substantial time for full-time employees.
Currently, Optum Rx has more than 25 drugs that can be automated through PreCheck Prior Authorization, including GLP-1s for diabetes, medications for attention deficit hyperactivity disorder (ADHD), irritable bowel syndrome (IBS), asthma and dry eyes. Based on the program’s results, Optum Rx and Surescripts are scaling PreCheck Prior Authorization across more health systems and additional drugs classes.
“It is amazing to take what is already there in the chart to automate prior authorization without any effort from the physician, pharmacist or staff. I feel the promise and excitement of automation actually happening and working, and hope it grows quickly."
Dr. Eric Boose | associate chief medical information officer, Cleveland Clinic
Learn more
Prior authorization is an effective tool to ensure appropriate use of high-cost therapies and cost-effective care. Optum Rx’s investment to be the first to market with an innovation that makes the process more efficient demonstrates our commitment to addressing provider pain points and accelerating the path to patient therapy.
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