NaviNet Admin on June 5, 2012

NaviNet 2012 Interview Series: Jocelyn Keegan on Drug Prior Authorizations

Jocelyn Keegan is the product manager of NaviNet Drug Authorizations. She champions the belief that electronic drug prior authorizations can get the right prescription medicine into patients’ hands faster and move the healthcare needle. In addition, she manages NaviNet’s partnerships with CoverMyMeds and CVS Caremark.

You were just out in Phoenix at the National Council for Prescription Drug Programs (NCPDP) 35th Annual Conference. What is attracting the most attention?
The ongoing impact of healthcare reform—from Centers for Medicare & Medicaid Services (CMS) rules to state-level mandates—is driving technology change. Health plans, pharmacies, and healthcare technology vendors are vying to keep up and understand the ramifications on their respective businesses. Drug prior authorization (PA) is a hot topic in every session I’ve attended.

You have championed the electronic prior authorization (ePA) solution. Why? What problems are you trying to solve?
Today, pharmacies, pharmacy benefit managers (PBMs), and provider offices are challenged by how to streamline the PA process to gather the most relevant clinical information. The challenges are many. For example, more than 90% of forms are still processed via fax. Providers often use out-of-date questions, incorrect forms, and even submit requests to the wrong PBM.

Our first goal is to get the provider the correct form as quickly as possible, so the information exchange can be focused on the most accurate clinical questions and patient information for a specific drug relative to a specific event with as little time and effort wasted for all parties.

Our secondary goal is to allow pharmacies, PBMs, and providers to create an electronic workflow that enables all of the parties to understand the status of a PA at any time—to essentially create an on-ramp to ePAs.

NaviNet and CoverMyMeds are actively participating in ongoing ePA pilot with CVS Caremark using the NCPDP candidate standards for adjudication. We will be able to begin to offer providers near-real-time access to the specific question sets for a particular PBM for a specific patient’s pharmaceutical needs, leveraging a direct connection to a PBM’s rules engine, enabling the PBM to automate straightforward decisions, and focusing the PBM and provider on cases that require additional clinical background information to reach a decision.

What are you hearing from PBMs about the solution?
PBMs continue to receive outdated or incorrect forms from providers. PBMs understand the value in participating in a multi-payer solution because they have had their own struggles to launch stand-alone ePA portals. While there is a lack of published data, we have found that provider utilization of these one-off solutions has been low.

The PBMs working with NaviNet and CoverMyMeds recognize the appeal in allowing providers to get to the right form quickly. They want to get fast accurate answers to PA requests, which can be easily determined by answering the correct questions and some branching logic. All of the PBMs we are working with have the understanding that the move from the current phone- and fax-based system will be an evolution for the industry. Our solution enables a plan to select the correct model of integration for their respective solutions today. In addition, we will work with them to identify the correct path to a fully integrated ePA solution.

What is the greatest benefit drug authorizations offer to the provider office?
A provider wants to ensure that patients can get their prescribed drug as quickly and painlessly as possible. Drug authorizations save providers time because a user can quickly obtain the correct form for a specific patient for a specific drug. For PAs that make it to the pharmacy without the correct approval, a pharmacy can now create an electronic fax request for the provider to complete the clinical data required for a decision. ePA will provide a near-real-time answer on the specific request versus having to wait for 48-72 hours for an answer, which is the case today.

How does ePA bridge the gap between the electronic health record (EHR) and other systems within a provider office?
In its ideal form, the ePA allows doctors to have a conversation directly with the patient about specific formulary options during the moments of care while the patient is in the office. When that is not possible, our solution will enable pharmacies and provider offices to work with electronic versions of virtually all plan forms to begin to more proactively gain the appropriate prior authorizations for their patients.

Many doctors may understand the need for a PA for a specific patient, but because of the way the system works now, and their desire to get the PA processed as quickly as possible, they often send the prescription through to the pharmacy in order to create the failed claim. A provider’s EHR, the pharmacy network tools, and the PBM’s rules engines are all separate closed solutions. Using a common tool allows each of these participants to create PAs in a common way, as we work with PBMs to improve the quality of the response from their systems.

What is the benefit to the consumer?
Today, an all-payer PA solution allows both non-expert and expert clinicians and staff to easily find and fill out the correct forms to expedite their access to the medication, improving the likelihood of medical adherence. The arrival of near-real-time electronic adjudication with a PBM directly will further decrease delays.

As e-prescribing tools—stand-alone and those imbedded in EHR platforms—improve to the point that they alert a provider when writing the prescription about the need for a prior authorization, the provider will be able to have a dialogue about a particular event and prescription option, eliminating some unnecessary PAs (for example, quantity limits, step-therapy requirements, and patient affordability issues) and allow providers to proactively communicate with the PBMs to complete the PA—and, even better, an ePA— before a patient arrives at the pharmacy. The improved process dramatically increases the likelihood of adherence, the ultimate quality goal of the solution.

When is the NaviNet ePA pilot starting? Will you tell us a little bit about it?
We will begin the NaviNet Drug Authorization pilot in June. The solution offers a tight integration with the existing CoverMyMeds workflows, allowing a NaviNet user the ability to create proactive PAs and respond to pharmacy-initiated PAs for virtually any drug from any payer in the country. Our pilot will begin with a small group of offices and run through July. Our goal is to expand the participant offices and add the ability for CVS Caremark patients to move from an electronic form to a patient-specific question set and auto-adjudication of the ePA. NaviNet and CoverMyMeds are working closely with CVS Caremark on their pilot, using one of the NCPDP draft standards for an XML ePA transaction.

To learn more or to join the pilot, please visit What do you think about the potential efficacy of this solution? Share your stories on our blog or connect with us on LinkedIn, Facebook, and Twitter.

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