Founder of PAFA highlights how they're helping to streamline the PA process for payers
A new initiative is changing the way prior authorization is handled.
Denise Balch, along with a small team, recently launched the Prior Authorization Framework and Accreditation (PAFA) Program, a Canadian non-profit focused on improving prior authorization processes and setting industry standards.
“It's not just about time to claims processing but it's also about the overall experience,” explained Balch, the founder and executive director of PAFA said in a recent webinar. “We saw that when we did the simplified prior auth research, we found that there was a lot of confusion.”
Stakeholders, particularly patients and physicians, were concerned that the information they needed to get claims submitted was not available to them, Balch explained, adding that “it was hard to find claim forms, and it was hard to find out what the actual process was.”
PAFA‘s goal is to encourage insurers, both public and private, to implement efficiencies in their claims processes. It also provides an accreditation program to recognize those who meet best practices.
However, Balch makes it clear about one thing. She’s not in the business of dictating criteria to insurers.
“It's not an organization that's going to tell a payer and dictate what their criteria should be. That's not what we're going to do. We know payers won't accept that. That’s a discussion that is off the table,” she said.
In its current state, the prior authorization process is often bogged down by paperwork and inefficiencies, leading to delays in medication access, administrative burdens, and unnecessary stress for those navigating the system.
The inefficiencies of prior authorization have a direct impact on patients. Those waiting for medications may be unable to work, or if they do, they may not be performing at their best due to untreated health conditions.
“It's very stressful waiting for access to these important and often life-changing or life-saving medications,” Balch said.
PAFA aims to address these issues by advocating for electronic prior authorization (EPA), which can significantly reduce the time it takes for claims to be processed. Right now, while many claim forms can be completed online, the final submission process still often relies on old fashioned means, like fax or mail.
“It still has to go by fax or mail. But in terms of the green circle with the patient, physician, and patient assistance, in many cases and for many forms now, they can be completed online with e-signatures,” she explained.
Balch suggests simply digitizing the form completion process can reduce the time spent on prior authorization by 70 per cent. The potential savings, both in administrative costs and in time, make a strong case for widespread adoption of EPA solutions.
Plan sponsors also need to be aware of how their insurers handle prior authorization. A slow or inefficient process can lead to frustrated employees who may struggle to access necessary medications.
Balch pointed out that even a few years ago, private insurers were resistant to the idea of reform, emphasizing in 2020, private payers asserted change wasn’t needed and “that everything was working fine.”
“Fast forward to 2023, payers now agree with the need for a move to EPA and improvements in the prior authorization process,” she said.
“Private payers in Canada recognize the need to move to digitization of several insurance processes that remain paper based including EPA. The benefits for all stakeholders are high, at a time when access to medical resources can be difficult. It helps relieve overall health care and the overall health care administrative burden,” she added.
That shift in attitude is even reflected in recent industry moves. Last June, OkRx and GreenShield received a grant from the Canadian Medical Association Foundation to develop EPA solutions, she highlighted.
PAFA operates on two levels: membership and accreditation. Insurers can become members by committing to PAFA’s guiding principles, which emphasize communication, transparency, fairness, consistency, and efficiency.
Accreditation, however, requires insurers to implement specific administrative efficiencies and, eventually, electronic prior authorization capabilities.
“Once an organization achieves both the admin and the EPA accreditation, then they will be awarded the gold accreditation standard, which will be the highest standard,” she said.
For insurers, the potential benefits of PAFA accreditation go beyond efficiency. It can serve as a competitive differentiator in the market, signaling to plan sponsors and advisors that they are committed to streamlining the prior authorization process.
Balch is encouraging plan sponsors and advisors alike to start pressing their insurers on this issue.
“This webinar is particularly a call out to say, start asking your insurers, your payers, are you accredited? Are you a member?” she said.
While accreditation isn’t available yet, insurers can already join as members, and Balch expects accreditation applications to open later this year.
While Balch sees this as a promising sign that the industry is finally ready to embrace change, the focus is currently on expanding PAFA’s reach, bringing more plan sponsors and insurers on board.
PAFA will run two more webinars on membership and management and the framework and accreditation on February 13 and February 27, respectively.
