The interest in prior authorization is growing, which is driving more interest in reforming current practices and policies to create efficiencies. This will improve communication, reduce time-consuming claims process and lower administration costs. Simplify Prior Authorization (SPA) and Prior Authorization Framework and Accreditation (PAFA) Program are helping to shape the prior authorization environment. The SPA and PAFA team are often asked how these two initiatives are different and what their role is. This blog will answer some of the questions you may have. If we don’t answer them all, then just email us at denisebalch@priorauthframework.ca.
1. What is SPA?
Simplify Prior Authorization (SPA) is an advocacy and educational initiative that was formed after the release of the report on Private Payer Prior Authorization in Canada in Fall 2020. It is managed by Connex Health with the support of a working group of industry professionals, and financial support of several industry stakeholders.
- What is SPA’s goal? To raise awareness of the impact prior authorization (PA) processes and practices have on plan members and their healthcare team, including the workplace, and advocate for improvements in the PA process.
- What has SPA done? SPA has worked hard since 2021 to provide group benefit stakeholders with information about current PA processes and practices and the improvements that are needed. There is an SPA information website simplifypriorauth.ca that anyone can use and find a history of podcasts, blogs, articles, videos, and webinars, as well as resources that can help stakeholders navigate the PA process. SPA has also collaborated with technology solutions providers to facilitate the development of an effective electronic prior authorization solution to move claims from a paper/fax-based model to electronic submission. This reduces claims time and the administration burden on all stakeholders in the claims process.
SPA is the “why” behind PA reform; why should we be advocating for change in PA.
2. What is PAFA?
The Prior Authorization Framework and Accreditation Program (PAFA) is a Canadian non-profit founded in 2024. It is managed by an Executive Director, a board of directors and an advisory board. An accreditation panel reviews applications. It is funded through members, associate members, and accreditation fees.
- What is PAFA’s goal? To encourage payers to adopt the PAFA Framework and recognize those payers who do so through the accreditation process, both administration and electronic prior authorization accreditation. This has several benefits. The Program provides payers who are accredited with a competitive advantage over payers who are not accredited, including lower administration costs, the bar is raised for PA processes and practices, and the patient journey through the PA claims journey is easier as is the experience of their healthcare team.
- What has PAFA done? Since November 2024 the PAFA team have developed the Program Guide that provides details of PAFA and accreditation, launched the PAFA website at priorauthframework.ca and welcomed several associate and payer members. Blogs and webinars are available on the website. The majority of the Advisory Board and Accreditation Panel are in place now. The team are in the process of finalizing the accreditation forms and the first Canadian PA survey.
In short, PAFA is the “how” behind PA reform; providing a framework and accreditation program for payers that will motivate them to evaluate and if necessary modify their processes and practices to meet the PAFA Framework and award them with accreditation and recognition.
3. Who is the target audience?
Every organization or healthcare stakeholder with an interest in PA is part of the target audience for these initiatives.
- SPA is targeted to all stakeholders in the PA process, including patients who are going through the prior authorization process for a specialty drug they have been prescribed. The website simplifypriorauth.ca has many resources to help patients navigate the process, which can also be useful for advisors.
- PAFA is targeted to public and private payers as well as non-payers.
Payers are encouraged to become members and involved in the continuous review and improvement of the PAFA Framework, including joining the advisory board*, and becoming accredited. Payers include insurers, pharmacy benefit managers, third party, and provincial payers.
Non-payers are encouraged to become associate members to PAFA to support the work, get involved in the continuous review and improvement of the PAFA Framework, and to become members of the advisory board and/or accreditation panel*. Associate members can include associations, group benefit advisors, drug access navigators, patient groups, patient support programs, and others with an interest in PA who do not adjudicate PA claims.
4. How do SPA and PAFA work together?
SPA continues to build awareness and advocate for the need for reform and engage a broad network of stakeholders. The feedback gathered through SPA, including the 2020 Report on Private Payer Prior Authorization in Canada, continues to inform the work of PAFA.
PAFA provides tangible deliverables through an accreditation and recognition program that is built on findings of SPA and the 2020 Report. The Program continues to rely on SPA to build awareness and advocate for the need for reform across stakeholder groups.
Together, SPA and PAFA create a comprehensive path to achieving a more efficient, transparent, and patient-centred prior authorization system in Canada.
5. Can organizations be involved in both?
Absolutely. Some of our partners are already supporting both SPA and PAFA. If your organization is considering supporting one or both, please reach out to Denise Balch at denisebalch@connexhc.com or denisebalch@priorauthframework.ca to discuss.
More to Come
The prior authorization teams at Simplify Prior Authorization and the Prior Authorization Framework and Accreditation Program are working on updates to the SPA website, finalizing accreditation forms for PAFA and a prior authorization survey. You’ll hear more about these soon over the summer along with reminders about information you may have missed earlier this year. Reach out to us anytime if you have an interest in finding out more about SPA or PAFA.
*Limited numbers are eligible to join the advisory board and/or accreditation panel at any one time.
