INTRODUCTION:

The prior authorization (PA) process is critical in providing some patients with their medically necessary products. It is the insurance or payers’ way of controlling costs by approving or denying certain medications, procedures, or devices that may not usually be covered or is on a higher tier on the formulary. It ensures that what the patient receives is medically appropriate for their situation. Each step of the process includes unique roles and responsibilities at the healthcare provider’s (HCP) office, the pharmacy, or the payer.

THE PHARMACY:

The pharmacy typically is the start of the utilization of the PA. The patient will bring in a prescription prescribed by their prescriber that will alert the requirement of a prior authorization once processed through the patient’s insurance. Prescriptions warranting this type of alert may include specialty medications or glucose monitoring products. The pharmacy then notifies the patient and the prescriber of this request. Sometimes, at specialty pharmacies where most of their products require a PA, pharmacists can directly work with the payer to accelerate this process to receive timely reimbursement and patient access. The responsibilities and education requirements for each role at this step of the PA process are listed below:

  1. Pharmacist: The pharmacist is mainly responsible for communicating with the provider’s office to process a prescription PA request or denial. They are also responsible for notifying patients of this requirement before getting their medication. A pharmacist’s education requirement includes having a Doctor of Pharmacy (PharmD) degree.
  2. Pharmacy Technician: The technician can also process the prescription through the payer and will be notified if there is a need for a PA. Technicians also support the pharmacist in communicating between the provider’s office and the patient. In order to practice, they must have a high school diploma. Some states require a pharmacy technician license or certificate.
  3. Pharmacy Billing Specialist (PBS): Typically, specialty pharmacies utilize a PBS to optimize the billing process through their knowledge of billing regulations and healthcare system codes.
  4. Managed Care Pharmacist (MCP): Managed care pharmacists can aid in the PA process by applying their medication knowledge in reviewing whether the medication is prescribed or taken appropriately.
  5. Patient Care Coordinator (PCC): The patient care coordinator’s role is primarily to act as a patient advocate from start to finish throughout their health journey, including any PA needs. They help the patient obtain a PA by communicating with the pharmacy and provider’s office. Most PCCs have a bachelor’s degree in social work, nursing, or public health.
  6. Medication Access Coordinator (MAC): The medication access coordinators work within the ambulatory clinic setting and help pharmacists, physicians, and clinic staff with the PA to obtain reimbursements for high-cost medications to avoid delaying the initiation of therapies.

THE HCP OFFICE:

Once the provider’s office gets notice of a PA request, they will gather the necessary information to submit to the payer. This process can include patient demographics, charts, labs, and any clinical documentation that will aid in proving the necessity of the medication or service. Retrieving, documenting, and submitting such forms to the payer can be done with the help of the prescriber, medical assistant, clinical documentation specialist, prior authorization specialist, medical coder, or case manager. The responsibilities and education requirements for each role at this level of the PA process are listed below:

  1. Prescriber: The prescriber can be a physician/MD, nurse practitioner (NP), or physician assistant. After thoroughly assessing the patient, they are responsible for prescribing the medically necessary medication or service. Education requirements for each include obtaining advanced-level degrees. All of these roles have additional state-required licensing exams before becoming a prescribing practitioner.
  2. Medical Assistant: The medical assistant’s role in this process is to assist the prescriber in filling out and submitting the PA form. This can include verifying information with the pharmacy and obtaining all required documentation from the patient’s health record, as mentioned above. Some employers may require them to obtain a CMA or certified medical assistant certification through the American Association of Medical Assistants (AAMA).
  3. Clinical Documentation Specialist (CDS): A CDS can help in the PA process by accurately documenting patient records. Accurate patient documentation is crucial for prior authorizations as it ensures that healthcare providers have comprehensive and precise information to support the medical necessity of a procedure or treatment. This precision minimizes delays and denials in the authorization process, facilitating timely patient care and reducing administrative burdens.
  4. Prior Authorization Specialist: These specialists help with everything that goes into the prior authorization process, from submitting a claim to reviewing and following up. The role varies on the setting that they are working from. For example, a PA specialist working from the pharmacy will be responsible for communicating the request to the prescribing office. In contrast, the specialist working on the payer end will ensure that all the information received is accurate to approve/deny the claim. A PA specialist typically only requires a high school diploma/GED, though many that step into this role already are pharmacists, nurses, or other healthcare workers who have obtained their respective degrees/certifications to practice.
  5. Medical Coder: A medical coder at this step of the process is responsible for submitting the PA form with the correct healthcare codes in compliance with the International Classification of Diseases Manual – Clinical Modification (ICD-9-CM) and the American Medical Associations Current Procedural Terminology Manual (CPT).
  6. Case Manager: A case manager helps patients by assessing their needs and devising a plan to meet them. This can include helping them obtain prior authorization by communicating with the pharmacy, prescribing office, or payer.

THE PAYER:

Finally, this step of the process determines whether the previous roles’ collaborative efforts have been proven successful. At this point, the pharmacy and the provider’s office should have submitted all required documentation to the patient’s health plan or payer. Prior authorization coordinators, clinical reviewers, medical directors, or utilization management specialists can assess and determine whether the submitted claim will be approved or denied. This is done following the health plan’s formulary or the criteria for a specific medication, device, or procedure being requested. Many plan’s have already or will be implementing artificial intelligence (AI) to aid in this step of the process through obtaining and cross-checking information that previously had been done manually. AI can automate decision-making in simple cases, whereas, in more complicated ones, it can aid in collating the necessary information needed to assist the payer in making a decision. The responsibilities for each role at this level of the PA process are listed below:

  1. Prior Authorization Coordinator (PAC): PACs verify/review the information received, communicate with the patient’s provider/pharmacy if additional information is needed, and facilitate the clinical review process. Many employers prefer if the candidate has clinical or medical coding experience.
  2. Clinical Reviewer: Clinical reviewers utilize their healthcare knowledge in compliance with the health plan’s formulary to determine the appropriateness of the prescribed medication/service. The clinical reviewer usually has some type of clinical background, such as nursing or medical assistance.
  3. Medical Director: When a claim is insufficient based on the payer’s guidelines or needs additional review for medical necessity, it will then be sent to the medical director. They are usually only involved in the PA process when necessary and may need to deny a case. Medical director positions are often held by doctorate-level clinicians such as physicians (MD, DO), pharmacists (PharmD), researchers (Ph.D.), and advanced degree nurses (DNP).
  4. Utilization Management Specialist: Utilization management specialists review the healthcare needs and treatment options available for patients on a case-by-case basis. They ensure that patients are appropriately utilizing the healthcare services available by their insurance. During the PA process, they can assess whether the medication, service, or device is appropriate for the patient’s treatment plan.

THE FINAL DECISION:

The approval or denial is usually sent to the HCP’s office that submitted the PA request; however, it can also be sent to the patient directly. In the case of a denial, an appeal can be made to provide more information that may justify the payer approving the PA. The typical prior authorization process from start to finish can take anywhere from one day up to a month, with payers usually giving a decision in 3 or more days, according to the 2018 American Medical Association (AMA) Prior Authorization Physician Survey. Delays in this process can affect a patient’s access to necessary services or their medication adherence. Each role within the PA process is responsible for improving their knowledge of prior authorizations to increase efficiency and minimize delays. Those looking to advance their knowledge and skills of prior authorizations can obtain certification through the first and only accredited Prior Authorization Certified Specialist (PACS) Program through the Accreditation Council for Medical Affairs (ACMA).

CONCLUSION:

In this article, we have discussed the various responsibilities and educational requirements for each role within the prior authorization timeline. It was determined that each individual must be accountable for their responsibility within the process to get an accurate decision from the payer efficiently. Educational backgrounds for each role was also identified. Overall, increasing one’s knowledge of the prior authorization process as a whole and their role within it can significantly improve delays in therapy and, thus, improve healthcare outcomes.

Kiana Dixson PharmD, BCMAS
Shakhzoda Rakhimova PharmDc 2024

References 

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