Prior authorization process often gets denied
Dean Erhardt, President and CEO of D2 Solutions, explains that prior authorization submissions often come back denied with no reason given, and the vast majority of rejections are administrative in nature. Something as small as a ZIP code that doesn’t match the city on the form can get a request thrown out.
Erhardt notes that submitting to each payer’s exact requirements for a given product can shorten delays that can stretch as long as three to four weeks for some products. He also highlights the importance of staff training on AI, which can start with a couple of classes a year.
Prior Authorization Challenges
Medical Economics Senior Editor Richard Payerchin sat down with Erhardt to discuss the challenges of prior authorization. Erhardt explains that reaching a patient about a pending approval can take as many as nine phone calls, and patients often field conflicting calls from the physician’s office, the pharmacy, and the payer.
Patients may never learn about copay and affordability programs, and practices need to weigh labor against technology costs. Erhardt points to staff turnover as a hidden expense and says training on a new platform should take about 15 minutes.
Technology and Workforce Shortage
Erhardt expects dramatic shortages by 2030 and says people nearing retirement now are more comfortable with technology than the generation before them. He points to digital therapeutics and wearables as part of care delivery and notes that technology can offset the workforce shortage.
He expects virtual consults that put a distant physician in a rural exam room, AI call centers, and patients to become comfortable with AI agents within 12 to 24 months.
Drug Access and Patient Care
Erhardt points to PBM reform, revamped manufacturer contracts, growing lists of non-covered drugs, and the risk of a race to the bottom on biosimilar prices as factors affecting drug access. He also describes enrolling patients in manufacturer programs straight from TV ads and screening them before they reach a physician.
Erhardt estimates that about 30% of patients don’t have a primary care physician and says patients will drive the shift toward virtual care based on convenience. He notes that patients will decide how they want to receive care and highlights the importance of investing in primary care, including setting aside telehealth time for patients who can’t take hours off work.
Erhardt’s comments on the patient who learns they have a disease that costs $250,000 a year to treat and doesn’t know what to do next highlight the need for better patient support and education. As healthcare continues to evolve, it is essential to prioritize patient care and access to affordable treatments.
