Best Practices in Plan and Prescriber Interactions-Improving the Organizational Determination and Coverage Determination Process

By December 17, 2019Audits, CD, CMS, OD

The Organizational Determination (OD) and Coverage Determination (CD) process can be a source of frustration for members, prescribers and plans. The updates to Chapter 13 and 18 highlight the expectation that plans and providers work together to ensure patients receive appropriate service authorizations and medications in a timely manner.

Following are some best practices in improving plan and provider interactions.

Use Multimodal Communications

Some provider offices rely heavily on fax while others are staffed to take phone calls. Making use of both phone, fax and/or electronic prior authorization can increase the response time to outreach attempts.

Conduct Peer to Peer Outreach

Via guidance and audits, CMS has made it clear that plans and providers should interact on a peer to peer basis.  This means physician to physician, pharmacist to pharmacist and or nurse to nurse outreach.  Scheduling interactions at some interval can allow for process review and ensure nothing slips through the cracks.

Dedicated Staff for Authorization Requests

Recognizing that authorizations are high volume and time consuming, plans and providers alike should have dedicated staff for managing authorization requests. Best practice staffing models utilize nurses and/or pharmacists that can review the criteria and ensure that clinical information to support the request is included.

What’s Next?

The Final Rule (CMS-4180-F) published in May 2019 will require Part D plans to adopt one or more real-time benefit tool by January 1, 2021. The tools will need to be integrated into electronic health record or electronic prescribing system and provide real time information about patient’s plan design and coverage

  • Formulary vs Non-Formulary
  • Utilization Management Costs
  • Out of Pocket (OOP) costs
  • Therapeutic alternatives

If your plan is seeking best practices for improving the authorization process, BluePeak can help. BluePeak helps plans assess their operational processes to achieve efficiency by implementing innovative best practices.