Evaluating the Effect of Proactive Interventions for Prior Authorization Recertifications on Continuity of Care in a Specialized Medicaid Population

Monday, April 27, 2020
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Soumya Vishwanath, PharmD
Commonwealth Medicine
Stephanie Tran, PharmD
Commonwealth Medicine
Thomas Pomfret, PharmD, MPH, BCPS
Commonwealth Medicine
Kaelyn Boss, PharmD
Commonwealth Medicine
Mark Tesell, PharmD, BCPS
Commonwealth Medicine
Mylissa Price, MPH, BS, RPh
Commonwealth Medicine
Caroline J. Alper, MD
Commonwealth Medicine
Lorean Muchnik, RPh
Commonwealth Medicine
Karen Clements, ScD
Commonwealth Medicine
Kimberly Lenz, PharmD
Commonwealth Medicine

Prior authorization (PA) is a formulary management strategy used to assess medical necessity and to encourage the use of effective and less costly therapies. This study assessed the effectiveness of a three-part, proactive intervention in prompting new PA submissions and/or provider response prior to PA expiration in a medically complex subset of a state Medicaid population. Outreach in the intervention resulted in a 3.6 fold increase in new PA submissions and/or provider response compared to a historical comparison group. On average, PAs were submitted 2.7 days prior to the expiration date in the intervention group versus 13 days after PA expiration in the comparison group, highlighting the influence of the proactive intervention on the timeliness of PA submission.