Prior authorization process improvement for pain medications in an oncology unit: Timely initiation of test claim request form.

Abstract

7050 Background: Oncology patients with extensive metastatic disease and advanced-stage cancer frequently require controlled medications for pain managements. Insurers require Prior Authorization (PA) for high-cost specialty medications including: Hydromorphone, Oxycodone, Oxymorphone, Fentanyl, Nucynta, Lyrica and Lidocaine patch. Failure to obtain PA may delay patient hospital discharge and attainment of discharge medications, increase patient medication costs, increase hospital readmissions and emergency visits, and exacerbate clinical complications. In order to avoid delays, providers must submit a Claim Request (CR) to initiate the PA process. PA usually takes 48-72 hours after the CR is submitted; therefore, timely CR submission in anticipation of discharge is imperative. Baseline rates for initiating CR in a timely manner was 15%. A quality improvement project was conducted to increase provider-initiated CRs for prescribed pain medications requiring PA and to demonstrate a sustainable process, anchored by development of new policy. Methods: The project revised the provider-initiated CR process by implementing the following interventions: The Electronic Medical Record (EHR) was modified to create a ‘quick link’ to facilitate CR form submissions. The link was made available to providers via their dashboard for easy access to the CR form.The medication reconciliation process was revised to require nurses to send reminders to providers for any of the seven discharge medications requiring CR submission for PA. A new component was incorporated into the discharge planning process by discussing PA and CR during interdisciplinary rounds. Providers and nurses were educated about the revised process. Results: Rates for timely CR submission were collected from the EHR biweekly for 3 months post-intervention. Post-intervention, 77% of timely CR claims increased from baseline of 15% to 87%. Due to the timely initiation of CR, some medications were deemed not to require PA, and the percentage of PA requirement reduced from 95% to 55%. In addition, up to 16% of patients had money refunded as a result of timely CR submission. Conclusions: The new process was effective for ensuring an efficient and effective process for patients who require high-cost controlled medications for pain management, reducing waste and providing a quality experience for the patient. As a result of the project, the new process has become policy and is now being used on other units in the institution for additional medications that requires CR and PA.