UMass Chan Medical School-Commonwealth Medicine, 333 South St, Shrewsbury, MA 01545-7807. Email:
Am J Manag Care. 2021 Nov 1;27(11):e395-e399. doi: 10.37765/ajmc.2021.88783.
To assess the effectiveness of a proactive provider intervention in prompting prior authorization (PA) submissions or provider response prior to PA expiration for medically complex Medicaid patients.
Pre-post outreach study with data from pharmacy claims and provider outreach.
The intervention and historical comparison (control) groups included expired PAs from December 2019 to February 2020 and from December 2018 to February 2019, respectively. Provider outreach, including telephonic and fax attempts, was conducted over a 2-week period prior to PA expiration. Outcomes were classified as positive or negative based on provider conversation coupled with the result (eg, PA submission) for the intervention group and based solely on pharmacy claims for the control group. The primary end point was the percentage of positive outcomes between the groups, analyzed via χ2 test. The time from PA expiration to the new PA submission was evaluated via t test.
A total of 342 outreach attempts were conducted for 270 PAs representing 193 unique patients. Outreach was more likely to result in positive outcomes in the intervention group vs no outreach in the control group (87% vs 25%; P < .00001). On average, PAs were submitted 3.5 days prior to expiration in the intervention group vs 13.0 days after expiration in the control group (t = -7.50; P < .00001).
Proactive outreach resulted in a greater percentage of PA submissions and a significantly reduced time to PA submission. These findings provide important information for payers in guiding clinical programs to enhance continuity of care among at-risk populations.
评估主动式医疗服务提供者干预措施在提示预先授权（PA）申请或在 PA 过期前做出回应以避免过期的有效性，以治疗患有复杂医学病症的 Medicaid 患者。
具有药房索赔和提供者外展数据的前后干预研究。
干预组和历史对照组分别纳入了 2019 年 12 月至 2020 年 2 月和 2018 年 12 月至 2019 年 2 月过期的 PA。在 PA 过期前的 2 周内进行了提供者外展，包括电话和传真尝试。结果根据提供者的对话和干预组的结果（例如，PA 申请）进行了分类（阳性或阴性），而控制组则仅根据药房索赔进行了分类。主要终点是两组之间阳性结果的百分比，通过 χ2 检验进行分析。通过 t 检验评估从 PA 过期到新 PA 提交的时间。
共进行了 342 次外展尝试，涉及 270 个代表 193 个独特患者的 PA。与控制组没有外展相比，干预组的外展更有可能导致阳性结果（87%比 25%；P < .00001）。在干预组中，PA 平均在过期前 3.5 天提交，而在控制组中则在过期后 13.0 天提交（t = -7.50；P < .00001）。
主动外展导致更多的 PA 提交，并且大大缩短了提交 PA 的时间。这些发现为支付方提供了重要信息，有助于指导临床计划，以增强高危人群的医疗服务连续性。
