Insurer tests TELUS pilot project on costly drugs

TELUS Health, Canada Life and Innomar Strategies are testing an “end-to-end” digital solution to accelerate prior authorization processing of often very expensive specialty drug prescriptions, which will expedite the claims adjudication process within employer-sponsored group benefit plans.

This pilot program is a first in Canada, the three partners say. TELUS Health designed the electronic prior authorization (ePA) solution. Canada Life will test it on its group insurance customers. Innomar Strategies, a subsidiary of the pharmaceutical company AmerisourceBergen, will assist with patient support services. It shares its expertise in this area with the Canadian specialty biopharmaceutical market.

The partners explain in their joint press release that prior authorization applies to certain prescription drugs. ePA determines whether a participant is approved to receive coverage under a group insurance plan for a specific drug prescribed by a physician.

Matter of time

The partners say they want to speed up access to specialty drugs. These expensive drugs require prescription approval before the cost of the drug is reimbursed to the patient. The digital solution should reduce the delays associated with the traditional paper-based approval process.

“These delays may last weeks or even months,” Luc Vilandré, President of TELUS Health and Payment Solutions, told the Insurance Portal. “The end-to-end digital solution will speed up the process exponentially,” he adds. “Delays can be reduced to a few days, or even hours in some cases.” The system covers the entire process, from patients and their doctors to the pharmacy and ultimately the payer of the claim, he says.

Paper: a hurdle, errors and fraud

With demand in Canada likely to heighten due to greater use of specialty drugs and the introduction of other drugs, TELUS Health's ePA solution is expected to have a significant impact on the entire health insurance plan industry, the partners believe. For example, a physician or patient support staff member will be able to initiate the prior authorization process through a web portal and transmit all necessary information directly to the insurer (forms, signatures, etc.).

More and more specialty drugs are emerging, and their average costs are rising, Vilandré says. The authorization process must evolve. “Unfortunately, a form completed by hand and faxed to us causes major delays and potential errors,” he adds.

Ryan Weiss, Vice-President, Product and Experience, Group Customer at Canada Life, told Insurance Portal how these errors can impact insurers. “Inefficient, paper-based processes have longer turnaround times and therefore slower service levels to members,” he said in an email. The problems associated with paper forms include fields not filled in, incorrect information and illegible handwriting, he points out.

Plan sponsors will know that their plan members are getting better service, while maintaining appropriate controls to deter fraud, abuse or misuse of high cost medicines, Weiss adds.

“Especially during COVID-19, paperless processes are not only preferred by our members, they help support public health guidelines,” he says. In his view, the program will encourage plan members to provide any missing information, resulting in faster turnaround on coverage decisions and quicker access to approved medications.

Accelerated by COVID-19

In fact, the prior authorization process for specialty drugs has been used for decades in countries such as Canada and the United States, Vilandré says. The proliferation of these drugs is making this process increasingly important. “

Prior approvals must be obtained before an order can go through the employer's group plan claims process. This includes assessing whether the right drug is being prescribed, and whether other treatments could be used,” he says.

TELUS Health explains why it chose Canada Life to test the solution. “Collaborating with a leader like Canada Life allows us to create and validate a unique digital experience for all stakeholders in the benefits continuum. This is an important step in our mission to leverage the power of technology to invigorate the entire industry, optimize whole systems and bring health benefits management into the future,” says Laura Mensch, Vice President, Health Benefits Management, TELUS Health.

Canada Life has seen similar digital solutions successfully implemented in other countries. “We have been monitoring the progress of electronic drug prior authorization (ePA) adoption in other countries, particularly the U.S., for many years. The advent of COVID-19 essentially escalated our plans and condensed timelines,” says Ryan Weiss.

Measuring results

The pilot program will evaluate the TELUS Health solution across the chain. Participating companies will assess its impact on process efficiency, consistency of adjudication results (a process that begins with a physician's prescription and ends with claim settlement), and the overall plan sponsor and member experience, the press release states.

“Before going to scale, you have to be able to measure results,” Vilandré says. Automation should enhance the adjudication process, he adds. If the pilot program, which should last several months, yields conclusive results, TELUS will be able to offer the solution to all of its insurance customers, including Canada Life, he says.

Weiss mentions the pilot program is targeting high-cost medicines to establish proof of concept because many drug manufacturers have patient support programs for these drugs, and can help plan members fill out ePA forms.

“To start, we are focusing on a proof of concept to fine-tune the process and technology and make any changes before a broader launch. Ultimately, we want this new digital-first process to be offered to all plans, but the outcomes of our proof of concept/pilot will help us settle on when that will happen,” Weiss explains.