The prior authorization (prior auth, or PA) process itself can be complicated and requires both communication and a cohesive healthcare team. The healthcare team involved in the PA process consists of a provider or physician, the pharmacy, the payer, and the patient. Each player on this team plays a part in successful and positive patient outcomes. As healthcare professionals, we have an opportunity to improve these outcomes by gaining an understanding of this multi-functional process and the roles of each player.
Imagine that you have the appropriate patient from a therapeutic standpoint but not the approvable patient from a managed care standpoint. The appropriate patient is indicated to initiate a new therapy based on the label after maxing the dose of the standard recommended medication. But, the patient is not approvable based on the final decision of the PA process. According to an American Medical Association (AMA) survey, 94% of physicians report that prior auths cause access delays to necessary care.
The key elements that every provider should consider when mastering the prior authorization process are good documentation, knowledge of insurance rules, and appropriate utilization of support services. Detailed documentation includes all pertinent information of dates, dosages, reactions, and explanations of use in the PA. These details will result in easy tracking and accessibility. Physicians should also know the rules for the specific payer. For example, one insurance company may require a lab result within 30 days of the PA while another insurance company may not require the same lab result until within 90 days of the PA. Other options available to increase patient access are patient assistance programs and industry-sponsored programs.
Within the healthcare team, pharmacists are key players in communicating information to the provider, the payer (insurance company), and the patient. Many patients are unaware that a medication must be approved by their insurance until they arrive to pick up their prescription at a retail pharmacy. A pharmacist communicates with the patient the steps involved in the prior auth process.
The key elements that every pharmacist should consider when mastering the prior auth process are increased communication, medication history collection, and knowledge of insurance pharmacy requirements. The pharmacy is a great source for the information needed for proper documentation because it holds the medication history snapshot of the patient. The pharmacy can provide allergy information, as well as the dates and dosages of the patient’s medication list. Community and specialty pharmacists should also be knowledgeable of which insurances are accepted as some insurance companies designate particular specialty pharmacies to use for approval.
A payer is a company that pays for a medical service or medication. Most commonly, an insurance company is a payer. Payer organizations are key players in the PA process because they are the receivers of PAs after intake. Prior authorization representatives review the medical necessity of a PA by using the appropriate guidelines based on a member’s plan. After review, this representative approves or denies the medication or service line. Prior Authorization Certified Specialists and experts of prior authorization should be employed by payer companies. The specialists within payer companies essentially have the final say in approving a medication or service line prior authorization for the patient. It would principally benefit the patient if the specialist is willing to review the disease state in which they are authorizing.
The patient is central to every healthcare team. The purpose of every prior authorization submitted is to help patients receive their medications or medical services to optimize their care. The AMA physician survey also reported 79% of physicians have experienced a prior authorization that led to patients abandoning their treatment. Because prior authorizations will not be abandoned any time soon, healthcare professionals must be skilled communicators in explaining the realistic expectations of the prior authorization process. Each player within the process can communicate to the patient their role in the process and maximize the resources available to them to increase patient access.
This is a simplified version for each player in the prior authorization process. The black arrows represent the patient going to the physician then the pharmacy. The red arrows are the rejection and requirement of prior authorization. The green arrows are the process of notifying everyone of the approval. Each player is important in the successful conclusion of this process: patient access. Patients need advocates who will fight for their care and capable professionals who work on their prior authorizations.
As we move into a new era in medicine and drug development where real-world evidence, patient centricity, and precision medicine are at the forefront of healthcare decision making, specialists who understand the prior authorization will be more important than ever.