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Automating the prior authorization process

Discover our latest innovation to the PA process — PreCheck Prior Authorization — which reduces approval times, appeals and denials.

November 25, 2024 | 3-minute read

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The process of prior authorization (PA) has long been a central component of a successful formulary and utilization management strategy. Used to confirm that a prescribed treatment is clinically appropriate, prior authorization promotes better health outcomes and cost-effective care by ensuring proper use of high-cost therapies.

Despite the many benefits of PA, the process itself is complex and can lead to additional administrative burden for providers and delayed access to care for patients. That’s why we have worked to simplify prior authorization through ongoing strategic technology investments and process improvements. The result of this multi-year effort is a more seamless and expedited approach to PA that reduces administrative burden for providers and gets medications to patients sooner without compromising clinical rigor.

Introducing PreCheck Prior Authorization

PreCheck Prior Authorization is the latest Optum Rx innovation to the PA process. Developed in partnership with health information network Surescripts, PreCheck Prior Authorization accelerates the path to patient therapy by automatically extracting relevant data from their electronic medical records.

By eliminating the need to manually input supporting clinical information, this industry-first innovation expedites the PA process with median turnaround times decreasing from 8.5 hours to under 30 seconds.1

After a prescriber submits a request via EMR, PreCheck Prior Authorization assesses if the request is available for automation. If so, the system retrieves targeted clinical data from the EMR to complete questions for the PA. After analyzing the question set, PreCheck Prior Authorization sends an automatic approval if the request meets the PA criteria.

A recent pilot program of PreCheck Prior Authorization conducted with the Cleveland Clinic yielded impressive results in both the patient and provider experience. For example, 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. There was also a decrease in physician abandonment rate of the prior authorization process, with the percentage of requests for which physicians receive a question set for additional information but never complete dropping from 31% to 25%.

“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,” says Dr. Eric Boose, associate chief medical information officer, Cleveland Clinic. “I feel the promise and excitement of automation actually happening and working, and hope it grows quickly."

Currently, Optum Rx has more than 25 drugs eligible for automation through PreCheck Prior Authorization. Based on the pilot program’s results, Optum Rx and Surescripts are now expanding availability of PreCheck Prior Authorization across more health systems and additional drugs classes.   

A history of innovation for the prior authorization process

PreCheck Prior Authorization builds on the Optum Rx legacy of data-driven improvements aimed at improving care experiences and decision immediacy for providers and patients to this vital cost management tool. The work to redefine the PA process began with creating the robust digital infrastructure to handle the numerous internal and external data flows inherent to this once manual process.

This modern digital backbone has enabled the creation of sophisticated digital tools intended to expedite navigation of the PA process. Currently available to over 950,000 providers through their existing workflow,  PreCheck MyScript® (PCMS) has changed the nature of PA. PreCheck MyScript gives prescribers unprecedented visibility into drug costs through real-time access to patient-specific PA information.

With PreCheck MyScript, doctors can run a “trial claim” while the patient is still in their office to discover exactly how much a given drug will cost. If out-of-pocket costs are a concern, PreCheck MyScript automatically highlights clinically appropriate, lower-cost alternatives.

We have also made improvements to the PA process to ensure new levels of ease and affordability for patients. MyScript Finder leverages our data backbone to give members additional transparency into the cost and coverage of their prescriptions. Accessing MyScript Finder via the online portal or mobile app, members can receive real-time updates on alternative medication suggestions and opt for the lowest cost options prior to filling their prescription. 

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Sources

  1. Optum Rx and Surescripts data. April - June 2024.