Prior authorization processes continue to grow year after year. With an ever-growing need to decrease costs, many health plans are increasing the number of prior authorizations required for both medical and prescription benefits. Prior authorizations are utilization processes used by insurance companies to determine coverage for healthcare.

What are the steps of prior authorization?

There are many steps for prior authorization, but I’ll simplify it. Typically, and historically for medication authorizations, the patient will find out about the prior authorization requirements at the pharmacy. The pharmacy will then reach out to the prescriber notifying them of the prior authorization. The prescriber’s office will either call in a substitution or start the prior authorization process. There are forms for each insurance company that need to be filled out. This process has been streamlined to some extent by CoverMyMeds, ApproveRx, and other companies. The forms are filled out, sent to the insurance where they then look at it and determine if the supporting documentation is enough to approve. They will then hopefully notify the stakeholders.

For a more comprehensive view of the Prior Authorization process, please click here.

Who can process a prior authorization?

The providers who can process prior authorizations depends on your area of practice or your employer. Currently, many pharmacies will deny contributing to the prior authorization process, but some processes are integrated in the workflow.

One example of a prior authorization conducted in almost all retail pharmacy settings is submitting Medicare Part B information for Blood Glucose Test Strips and other glucose testing products. Many large retail pharmacy chains contribute to these processes and submit additional documentation for these Medicare Part B approvals. Guess what? That’s inherently a prior authorization process.

Some independent pharmacies provide more comprehensive prior authorization services to local prescribers to ease the administrative burden and see larger reimbursements. This can differentiate independent pharmacy and provide valuable services to local prescribers. This requires collaboration from the prescribers and their staff as additional clinical documentation or chart reviews are needed. Please keep in mind your local regulations and HIPAA releases involved in collaborating on patient care.

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Often, specialty pharmacies will process prior authorizations from start to finish for prescribers. This is because the medications are expensive, and the pharmacy is seeing the direct reimbursement and revenue from the treatment. With specific team members dedicated to prior authorization, the patient can get access to their medications faster and in turn the pharmacy can get paid just as fast.

Some clinical pharmacists at health systems will take on or contribute to the prior authorization process. They are a member of the team, often have collaborative practice agreements, and conduct chart reviews. Prior authorizations can fit in the scope of their pharmacy practice and increase the value of the medical practice.

As for pharmacy technicians, there are roles that already designated to the prior authorization process. Pharmacy technicians have other opportunities outside retail pharmacy. Understanding that your knowledge is applicable in other settings is the first step to expanding your career options.

What is CoverMyMeds? Can it be used in all prior auth cases or just specific cases?

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CoverMyMeds is an online platform that submits insurance claims. It asks the necessary questions and puts them all in one place. It is now used for a lot of medication PAs, but prior authorizations have a larger scope than the pharmacy benefits section of a health plan. CoverMyMeds can be started in any setting as long as you have an account, but if you don’t have all the clinical information, passing the started prior authorization back to the doctor’s office can be difficult.

As I said above, CoverMyMeds deals with the pharmacy benefit. It is in the name – CoverMyMeds.

Does the pharmacy play a role in appealing a rejected prior authorization?

Sometimes prior authorization denials are sent directly to the patient (e.g. denial letter, explanation of benefits). Understanding these documents can help with the next step regardless of your role in the healthcare process.

Sometimes prior authorization denials are sent directly to the patient (e.g. denial letter, explanation of benefits). Understanding these documents can help with the next step regardless of your role in the healthcare process.

Did you know that appeals are often required to be written from the patient to the insurance company?

Most doctors and patient advocates have gotten smart about this and have a release form during the patient onboarding process. This allows them to write an appeal letter on behalf of the patient, so they have permission at the start of the prescriber-patient relationship.

Healthcare providers (e.g. pharmacists, pharmacy techs, patient advocates) are all capable of helping a patient put together documentation to support their appeal. Just keep in mind the compliance standards and federal law about the permissions to access Protected Health Information (PHI).

Can prior authorization become a function of pharmacy practice?

The short answer, yes. The long answer is it will take some work to get there, but it is a good possibility.

Prior authorizations are currently a common practice in specialty pharmacy practice. These best practices can be translated well to other areas of pharmacy. Specialty pharmacy invests in processing prior authorizations because the monthly drug spend for specialty products is frequently over $2,000 per patient. So, specialty pharmacy decided to stop putting their finances into the hands of physicians who have plenty of other things to do. Other areas of pharmacy can also take back control of their revenue in the same way.

Pharmacists have the clinical knowledge to support more complex prior authorization functions. Both pharmacists and pharmacy technicians can be trained in the prior authorization process to ensure timely approvals.

Becoming a Prior Authorization Certified Specialist (PACS) gives you the opportunity to be the expert. You will know how to navigate the prior authorization process with ease and help patients get access to much needed medication.