A growing number of complex, expensive medications are entering the market. At the same time, health insurance companies, also called payer, are increasingly relying on utilization management to control healthcare costs by influencing patient care decisions. Common utilization management tools include prior authorizations, step therapy, predeterminations, and preauthorizations.
The legislation will streamline the prior authorization process for the more than 28 million Medicare Advantage members. Medicare Advantage (MA) plans, sometimes called “Part C” or “MA Plans,” are Medicare-approved plans from private companies offering an alternative to original Medicare for health and medication coverage.
Prior authorizations (prior auths or PAs) are a cost management tool utilized by insurance companies. PAs increase administrative costs for HCPs and create a healthcare obstacle for patients. HCPs depend on prior authorization approvals and insurance payments to remain in business. Healthcare providers (HCPs) must master a productive prior authorization workflow to improve productivity and revenue.
Health insurance companies increasingly employ cost management strategies as more expensive, specialized drugs enter the market. The use of step therapy is one of these cost-control strategies. The goal of step therapy is for patients to try low-cost medications before moving on to more costly ones.
Imagine a world with fewer prior authorizations. A new Texas law aims to make this dream a reality. House Bill 3459(HB 3459), or the “Gold Card Act,” grants prescribers a “continuous prior authorization exemption” if they have a 90% approval rating on previous authorization requests.
The prior authorization (prior auth, or PA) process itself can be complicated and requires both communication and a cohesive healthcare team. The healthcare team involved in the PA process consists of a provider or physician, the pharmacy, the payer, and the patient. Each player on this team plays a part in successful and positive patient outcomes.
Patient access is at the forefront of healthcare policy and mainstream media as the pandemic and vaccination distribution continues. In 2020, we saw vast attention on prior authorization, patient access, and related-issues making appearances in healthcare policy. We saw time spent on Step Therapy, Copay Accumulators, Prior Authorizations, and Out-of-Pocket Costs at the local and […]