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Are you Ready for the Surge?

Updated: Sep 17


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The COVID-19 coronavirus situation has temporarily caused many changes in the medical world. As the stay at home orders went into place, most non-urgent medical visits and procedures were cancelled or postponed. Eventually some of the non-urgent visits were converted to telemedicine visits. In response to the pandemic many health insurance plans relaxed drug Prior Authorization (PA) restrictions as well as extended PAs that were expiring within the next several months. In addition, with providers only seeing majority of the patients through telemedicine they were unlikely to start many new therapies which require PA due to the necessity of a full and thorough examination of the patients as well as additional laboratory testing. This has led to a temporary decline in prior authorizations. However, as we continue to implement mitigation measures and seek to the continuation of flattening the curve there will be an increase in the PA requests for drugs, non-urgent, and elective procedures as the non-urgent medical visits are rescheduled.


The AMA has published guides for physicians for reopening medical practices to ensure the safety of medical employees and patients, to minimize the spread of the virus, and to avoid a second surge in COVID-19 infections. Adhering to the guidelines will require medical office resources to be reallocated. Office staff who were previously responsible for obtaining prior authorizations for drugs and procedures may have additional responsibilities related to safe office practices due to COVID-19 which limits the time available to spend on PAs.


Volumes of PAs may increase more than payers planned. How will payers accommodate for those? Are payers prepared to handle this surge and still meet the required turn-around-times?


Our clinical team expects that PA volume will increase across the board, especially for drugs such as those for the treatment of Hepatitis C, biologicals for Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA), Ankylosing spondylitis, Crohn’s Disease, Psoriatic Arthritis, Plaque Psoriasis, Ulcerative Colitis, Hidradenitis Suppurativa, and Uveitis. Similarly, there is an increased anticipated demand for elective procedures and related treatments. These PAs often have lengthy criteria and require a significant amount of clinician time.


AHIP anticipates an increase in the volume of PAs for non-urgent and elective procedure PAs and is urging their members to extend previously approved authorizations for procedures which were not performed due to the pandemic. Extending the previously approved authorizations by at least 90 days or until procedure backlogs are cleared will allow resources to be used elsewhere. AHIP also recommends getting caught up with routine and preventive care such as well visits, screenings, and vaccinations which were deferred due to COVID-19. Appropriate resource allocation will be challenging during this period as we get caught up with all of the postponed services while at the same time addressing the current needs for non-urgent and elective procedures, well visits, screenings, and vaccinations. PA extensions will help stem the rise of the re-authorization of existing PAs but will do nothing to combat the surge of new PAs that will be incoming. Since submission and completion of new PAs is much more resource intensive than for reauthorizing an existing PA, providers will be looking for solutions that can assist in and simplify the PA process.


AHIP continues to encourage enhancing efficiency and streamlining administrative processes such as those for prior authorizations through automation and electronic information exchange.


New technology is available to assist payers. Banjo Health offers several solutions that can offer payers the ability to significantly decrease the overall time required in PA review from PA intake through final decision making.


  • Harmony PA is a comprehensive PA Management platform, for both medical and pharmacy prior authorizations (PA). Harmony’s user interface is intelligible requiring minimal training for end users, it allows users to arrive at a PA decision in just a few steps, and creates a full clinical data pathway continuum from the prescriber to the payer, by integrating provider and hospital Electronic Health Record (EHR) systems with the Health Plan and/or PBM’s Formulary, claims, and PA criteria and PA systems. Harmony optimizes the reviewer’s ability to complete a PA review in a fraction of the time required to review PAs traditionally by streamlining the PA workflow and presenting all relevant clinical information. Harmony can instantaneously search, identify, and list all relevant clinical information pertaining to specific PA criteria from hundreds of pages of supplemental documents submitted by providers. Harmony analyzes all incoming PAs for complexity allowing an equitable distribution of PA to all reviewers of simple and complex cases. Harmony’s reporting dashboard provides real-time monitoring of all PAs with multiple built-in alerts to help ensure compliance with all regulatory and internal requirements.


  • Virtuoso AI extracts clinical information from PA requests, compares the clinical data and information against the payer’s clinical criteria, and then accurately predicts if the request should be approved or denied. The AI model determines if there is missing information or additional supportive documentation is needed to complete the review and can flag PAs which require further clinician review. Virtuoso goes beyond decision support, Virtuoso’s proprietary model provides transparency to the PA process by generating the specific reason for approval or denial, ensuring compliance with internal audits as well as all regulatory agencies. Virtuoso learns, adapts, and improves itself as it processes more and more PAs. There are no limits to the efficiencies that Virtuoso can provide for your utilization management team.


  • Concerto Suite cuts PA reviewers time slogging through lengthy PA submissions that sometimes have over 50 pages of supporting docs by utilizing keyword search. All PAs upon submission are converted into searchable documents instantaneously. This is crucial for meeting strict Turn-Around-Time requirements in PA review plus greatly improves overall PA productivity. Concerto is built to be integrated with all leading electronic Prior Authorization (ePA) providers as well as call centers handling faxes and phone calls.


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