As we navigate the ever-evolving healthcare sector, the importance of field reimbursement and patient access teams continues to grow. With an increased focus on healthcare reform and patient advocacy, these teams play a crucial role in ensuring patients receive the treatments they need without undue financial burden. Here are five key strategies for field reimbursement teams looking to excel and make a significant impact in today’s healthcare environment.

Prior Authorization Workforce: The Demand for Certified Specialists

The Challenge of Prior Authorization

According to the 2022 American Medical Association survey of physicians, prior authorizations contribute to 94% of patient care delays. If a care delay occurs, it prolongs the patient’s access to the originally prescribed product. Then, there is a delay in better health outcomes and further a delay in improvements of care. According to the 2018 American Medical Association survey of physicians, prior authorization issues contribute to 92% of care delays. 29% of patients who endure the prior authorization process end up with the originally prescribed product and 40% of patients end up abandoning therapy. This means that about 70% of the market are not obtaining their vital medications to have better health outcomes and see the health improvements they yearn for.

Prior authorizations are an expensive component to the healthcare industry. For providers, it costs an average of $11 per authorization and they do not get reimbursed for it. Providers do not have the time or money to spend on the number of prior authorizations that they endure.

For payers, it costs about $12 per authorization and their own utilization management processes are costing them money to uphold. With specialty pharmacies, prior authorizations are making it more difficult to maintain adherence and keep the patients on therapy. Prior authorization is an expensive asset to the healthcare industry as it costs $32 billion dollars annually.

Furthermore, prior authorizations are complex transactions. In 2022, ⅓ of the prior authorizations were being handled by fax and phone. Only 54% were handled through web portals. Within every prior authorization, there can be multiple steps to obtaining approval and authorizers have to navigate a series of web portals depending on the payer. Many times, authorizers are expected to track down the medical chart or a member of the medical team to provide the information needed for a claim. These all contribute to loss of time and money.

The Anticipated Increase in the Burden of Prior Authorizations within the Specialty Drugs Market

Currently, specialty drugs contribute to 33% of the medical spend and retail drugs contribute to 33% of the medical spend. Prior authorization is a form of utilization management and the primary way to manage healthcare spend.

The change in PA burden over the last 5 years was an increase of 86%. This was reaffirmed in the 2019 AMA survey of physicians where over 86% of the respondents report prior authorization burdens have increased over the last 5 years. Physicians and their staff are spending over 14 hours of their time working on prior authorizations and it is not a source of revenue for them.

The Limitations of Prior Authorization Software Solutions

Expanded access programs exist to provide access to medications that are still in clinical development to patients who need them. If a drug is approved but not on the patient’s formulary, it will require a prior authorization. This causes a burden and will eventually delay patient care. Many HCPs are unfamiliar with the prior authorization process and therefore if an HCP needs to complete a prior authorization they will end up switching the product all together. Physicians do not have the knowledge or time to understand the denial and appeals process and therefore this is where the Prior Authorization Certified Specialist (PACS) program comes in.

The Necessity of Certified Experts in Prior Authorization Staffing within PACS

Prior Authorization Certified Specialist (PACS) Program is an online program with the following format:

• Accredited
• Self-paced
• Online
• Mobile friendly
• Simple interface
• Easy navigation

The target audience of this program is:

• Reimbursement and sales teams
• Clinics/hospitals
• Specialty pharmacies
• Allied health providers
• Market/patient access

The curriculum includes the following:

• 12 e-modules
• Glossary
• Case studies
• Downloadable resources
• Knowledge checks
• Final assessment

The PACS program was put together by over 30 industry experts and it has been the only training program created for prior authorizations for years. After completing the program and the final assessment, you are provided the PACS designation as a credential because it is an accredited certification program.

There are 4 important key areas of the PACS program. They include technical competencies, clinical understanding, regulatory and compliance, and minimizing denials.

A PACS certification must be renewed every 3 years and the path to renewal are two ways: passing a final exam or completing 10 hours of CE. Benefits of certification include ensuring your team keeps up with the most current environment, saving time and money, demonstrating the company’s commitment to excellence, and gaining a unique opportunity.

ACMA is making an impact as it was shown to be statistically significant in increasing knowledge of 80% upwards and a p value of < 0.0001. In an environment with increasingly more complex drugs and procedures, having certified prior authorization professionals to support prior authorization submissions and write letters of appeals is key.

Summary

Overall, PACS is an accredited program developed by experts and tested by regulators. It is interactive with cutting edge technology and the content is safe and secure for individuals that access the actual learning system. Over 200 companies have been certified including PBMs, pharmacies, wholesalers, pharma organizations, and clinics.

The impact of prior authorizations on the healthcare system is evident through various surveys and statistics. The delays in patient care resulting from prior authorization issues underscore the urgent need for reform in this aspect of healthcare management. The financial burden on both providers and payers, amounting to billions of dollars annually, further emphasizes the inefficiencies of the current prior authorization system. The complexity of these transactions contributes to the loss of valuable time and resources.

The escalating burden over the years, with an 86% increase in the last five years, necessitates innovative solutions. By bridging the knowledge gap and equipping professionals with the necessary skills, the PACS program aims to streamline the prior authorization process and mitigate its negative consequences. The impact of ACMA in significantly increasing knowledge, as evidenced by a statistically significant 80% improvement, underscores the program’s effectiveness. As the healthcare industry continues to deal with the challenges of prior authorizations, initiatives like the PACS program offer a more efficient and streamlined future for patient care and healthcare management.