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IngenioRx’s Prior Authorization Process is Faster, More Efficient




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Studies indicate 15% to 30% of care in the U.S. is unnecessary.1 In pharmacy care, this means that doctors may prescribe drugs that are excessive or not supported by medical evidence. Prior authorizations (PAs) help ensure patient care is safer, more effective, and consistent with clinical evidence.

Despite its necessity, the PA process can be frustrating for providers, payers, and patients. That’s why we’re working to give our members access to safe, timely, and affordable care through proactive PA.

Jeff White introduces proactive prior authorization

Jeff White, VP of Clinical Pharmacy Services, explains the importance of Proactive Prior Authorization

The PA experience should be a positive one. Our goal is to provide essential drug treatments, therapies, and medications to our members at the right time. We’re dedicated to fast-tracking decisions regarding drug treatments so they can be made as early as possible, based on the latest clinical evidence. By simplifying the PA process, we can help:

  • Prevent over-prescribing, which can lead to the abuse of medications such as opioids, benzodiazepines, and drugs prescribed for attention deficit hyperactivity disorder (ADHD).

  • Offer timely, appropriate care to members with minimal disruptions.

  • Lower members’ out-of-pocket costs by ensuring they receive appropriate medications.

  • Deliver significant cost-savings to providers by reducing time spent on PA transactions.

“Prior authorizations help ensure patient care is safer, more effective, and consistent with clinical evidence.”

What We're Doing + Why It's Working

IngenioRx’s proactive PA process focuses on timeliness, scientific accuracy, and provider feedback. Here are key measures we’re taking to achieve these goals:

Smart Utilization Management (UM) Process: IngenioRx has developed a best-in-class smart UM process that uses proprietary support tools such as:

  • Automating decision-making: The use of artificial intelligence (AI) speeds up and automates PA reviews through stored member, provider, and clinical data. Our system can automatically complete a PA when we identify a required medical diagnosis in a medical claims system.

  • Automating the utilization review process: IngenioRx uses predictive analytics to automate the utilization review process in real-time when PA requests are received electronically or through our Interactive Care Reviewer (ICR) portal. Members and providers can submit a PA for approval before a prescription is sent to a pharmacy. If approved, the pharmacy claim then pays without interruption.

Improved Electronic Prior Authorization Process: Electronic PAs (ePAs), which integrate with electronic medical record data, are the fastest way to submit and receive PA reviews and determinations. Providers can submit through their electronic medical record systems if the systems have ePA capabilities. ePAs are easier for providers to use and faster than traditional phone and fax methods. As a result, health plans’ operational efficiencies are increased, and members receive PA determinations sooner. In a study published by the Journal of the American Pharmacists Association, a pharmacy ambulatory care clinic using ePAs realized a 62% decrease in PA turnaround time.2

Enhanced Utilization Management (UM) Portal: IngenioRx uses an innovative provider-facing UM portal known as the Interactive Care Reviewer (ICR). The ICR allows providers to submit electronic PA requests 24 hours a day and track their status.

Quarterly Reviews: IngenioRx reviews our clinical criteria quarterly and whenever new clinical evidence is available. In addition, we identify drug services, therapies, or treatments with high approval rates to determine if a PA requirement should be removed.

The Bottom Line

IngenioRx is committed to enhancing our PA process, and our improvements are working. To date, we’ve reduced approximately 133,000 PAs per year (12% of total PAs) and successfully approved 800,000 ePAs in real-time.3 We will continue to find new ways to save time and money for members and healthcare providers. If you’re a provider, you can learn more about our ePA process, including how to submit a PA request and whom to contact if you have questions.

"Our goal is to provide essential drug treatments, therapies, and medications to our members at the right time."

1. Lyu, Heather, Tim Xu, Daniel Brotman, Brandan Mayer-Blackwell, Michol Cooper, Michael Daniel, Elizabeth C. Wick, Vikas Saini, Shannon Brownlee, and Martin A. Makary. 2017. “Overtreatment in the United States.”  

2 Birdsall, Ashley D., Ashley M. Kappenman, Bryce T. Covey, and Matthew H. Rim. Implementation and impact assessment of integrated electronic prior authorization in an academic health system, Journal of the American Pharmacists Association, July 2020.

3. Internal IngenioRx data, 2020.