Streamlining access: Centralized prior authorization management improves efficiency and patient care
Authors: Hank Aftewicz and Jessica Hodle
A centralized prior authorization (PA) management process was implemented for electronic PA (ePA) requests originating from 38 of Geisinger’s primary care clinics.
This initiative involved transitioning all ePA volume to the Centralized Clinical Pharmacy Services (CCPS) team, with the goal of developing a standardized and structured workflow, reducing therapy delays, improving outcomes for patients and reducing clinic staff responsibility. By centralizing this function, Geisinger aimed to streamline medication access and reduce administrative burden at the point of care.
In the centralized model, PA requests are handled by a dedicated team of experts, including pharmacy technicians and clinical pharmacists, who are well-versed in payor requirements, therapeutic alternatives and documentation standards. Their specialized knowledge allows for more efficient navigation of complex payor criteria and supports timely resolution of medication access barriers.
A key component of the new workflow was the integration of clinical decision support tools and access to payorspecific criteria. Leveraging these tools, the new CCPS workflow reduced the average time to treatment by 2 full days, significantly improving patient experience and continuity of care.
Notably, 28% of all PA requests received since the initiative began were able to be resolved without submission to the payor.
Pharmacy technicians contribute to this by assessing brand/generic payor preferences, copay card use, secondary insurance coverage and specific manufacturer payor preferences. This proactive approach reduces unnecessary delays and improves
first-pass success rates. If a technician is unable to resolve the request, a clinical pharmacist quickly determines if a covered alternative medication could be recommended to the prescriber so patients receive timely and appropriate therapy.
Of those requests that were submitted to payors for review, 71% received approval.
This high success rate is attributed to the CCPS team's familiarity with payor requirements and a standardized workflow with access to payor portals and policies. The team’s ability to anticipate documentation needs and align requests with coverage criteria has been instrumental in achieving these results.
The integration of ePA with existing telephone PA workflows has resulted in CCPS managing approximately 3,000 medication PA requests per month. The centralization of ePA management for 38 primary care clinics into the CCPS has led to measurable improvements in efficiency, approval rates and patient care. This model has also reduced variability in PA handling across sites, creating a more consistent experience for both providers and patients.
By leveraging a dedicated team, standardized workflows and clinical expertise, the organization has created a scalable model that supports timely, accurate, patientcentered medication access. Future enhancements include integration of artificial intelligence to further automate and optimize the process, as well as collaboration with Geisinger Health Plan (GHP) to develop a comprehensive front-to-back solution for PA management for health system and GHP members. These innovations will help keep Geisinger at the forefront of efficient, value-driven medication access strategies.
