Editor’s Note:

The article below summarizes the SUPPORT for Patients and Communities Act” (aka HR6 and Public Law 115-271). In June 2019, CMS proposed a new transaction standard for the Medicare Prescription Drug Benefit program’s (Part D) e-prescribing program as required by the SUPPORT Act.  If finalized, the proposed rule (CMS-4189-P) would require Part D plan sponsors and prescribers use version 2017071 of the NCPDP SCRIPT standard by 1/1/2021 for electronic prior authorization (ePA) transactions between prescribers and dispensers regarding Part D covered drugs to Part D-eligible individuals.

By Tony Schueth, CEO and Managing Partner

Changes are coming to electronic prescribing (ePrescribing) under Medicare Part D, as part of sweeping new legislation concerning the opioid epidemic that was signed into law on October 24. The new law is the “Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act’’ or the ‘‘SUPPORT for Patients and Communities Act” (aka HR6 and Public Law 115-271).

Among the Act’s dozens of treatment, prevention and enforcement provisions are two mandates for ePrescribing under Medicare Part D. They are:

• ePrescribing for controlled substances. Section 2003 mandates that prescriptions for all controlled substances covered under Medicare Part D must be transmitted electronically beginning on January 1, 2021, with a few exceptions.
• Electronic prior authorization (ePA). Section 6062 mandates that all covered Part D drugs requiring a prior authorization, if submitted electronically to Part D sponsors and processors, be submitted and responded to electronically by January 1, 2021 using a standard to be defined by the Secretary of the Department of Health and Human Services (HHS). In addition, facsimiles, proprietary payer portals that do not meet standards specified by the Secretary, or electronic forms don’t count as complying with the law. Further under Section  (ii) (III) of the SUPPORT Act, it says "the Secretary may require the use of such standards adopted," presumably with exemptions/exceptions for the mandated use. (Editor’s Note: This section  was updated after the original article was published.)

Impacts.  We see several potential impacts from these provisions, including:

• They will spur adoption of EPCS and ePA. Both EPCS and ePA have been around for a while but have not experienced the adoption uptick that was originally expected. These Part D mandates will change that. We expect that prescribers who are required to use EPCS for Part D prescriptions will ePrescribe controlled substances for commercial lives as well. Similarly, they will get used to using ePA and use it across the board. The vast majority of physicians accept Medicare patients, so their required use of the two transactions should give adoption rates a huge shot in the arm.

• Medicare is a huge tide that lifts all boats. Private payers and states are likely to follow suit and require EPCS for all controlled substance prescriptions, not just a subset. They are likely to require use of ePA as well.

• States will enact or change their laws to sync up with these Part D requirements. States already had been working to enact or develop EPCS legislation. This new Part D mandate should hasten their passage and given ammunition for advocates whose legislatures are dragging their feet. The same thing goes for ePA. While many states have ePA requirements, they are all over the map. Some even allow use of faxes and standardized paper forms. The new Part D ePA mandate will push states to conform to Medicare’s requirements.

• The absence of a named standard for ePA could lead to more retrospective PA, in which PA is electronically initiated by the pharmacy after a claim rejection. Retrospective PA is better than fax, phone and paper but nonetheless a burdensome, usually propriety process. Retrospective PA frequently results from missing or incomplete data in the current ePrescribing process. In an EHR, ePA is triggered based upon an indicator, or flag, in the formulary and benefit (F&B) file provided by the payers and pharmacy benefit managers (PBMs). However, the PA flag is frequently not populated by commercial payers. Even when the flag is provided, the need for PA is not always accurately presented. These inaccuracies, plus the traditional manual paper and fax-based prior authorization process, result in delays and frustration.

• The new ePA mandate will push for innovative solutions to predict if a PA is needed. Artificial Intelligence (AI) is one that some organizations are testing. Another is the Real-Time Pharmacy Benefit Check (RTPBC). The RTPBC provides real-time patient level information at the point of prescribing, pulled directly from the payer’s claims system, which is where the most accurate and timely information is stored. It enables the prescriber to see patient-specific plan restrictions (such as PA and step therapy), true out-of-pocket costs for a medication (specific copay/coinsurance amount) and specific deductible information. This will prevent dispensing delays caused by inadvertent prescribing of a drug that is not covered by the patient’s insurance or requires an expensive copayment.

What’s next? These mandates will advance use of health IT to positively impact provider workflow and efficiency. At the same time, some will substantially impact EHR and other technology roadmaps. Point-of-Care Partners is monitoring both legislative and implementation issues surrounding these mandates. For information on state and federal ePrescribing mandates and other requirements, contact Keith Fisher (keith.fisher@pocp.com), who co-leads our Regulatory Resource Center (RRC). Stay tuned for future articles and blogs on implementation issues.

For more insights on how HR6 will impact ePrescribing, ePA and PDMPs, read our article in HIT Perspectives.

If you’d like to know more about the changing health IT landscape and what it means for your organization, drop me a line (tonys@pocp.com)