A growing number of complex, expensive medications are entering the market. At the same time, health insurance companies, also called payer, are increasingly relying on utilization management to control healthcare costs by influencing patient care decisions. Common utilization management tools include prior authorizations, step therapy, predeterminations, and preauthorizations.
Tag Archives: prior authorization
Utilization Management: Here’s What You Need to Know
A growing number of complex, expensive medications are entering the market. At the same time, health insurance companies, also called payer, are increasingly relying on utilization management to control healthcare costs by influencing patient care decisions. Common utilization management tools include prior authorizations, step therapy, predeterminations, and preauthorizations.
5 Tips to Become a Field Reimbursement Manager
Field reimbursement managers (FRMs) are the backbone of a life science organization. FRMs support commercial (i.e., sales teams) with the patient reimbursement journey, ensuring patients receive therapy in a timely and cost-effective manner and assisting life science organizations with their primary objective of improving patient lives.
The Impact of Prior Authorization on Patient Compliance and Adherence
As medications become more intricate and expensive, medication access barriers prevent patients from acquiring their prescriptions and continuing medication regimens. The prior authorization (PA or prior auth) process is one of the access obstacles patients face when trying to acquire their medications.
Electronic Prior Authorization Reform: What’s Next?
The legislation will streamline the prior authorization process for the more than 28 million Medicare Advantage members. Medicare Advantage (MA) plans, sometimes called “Part C” or “MA Plans,” are Medicare-approved plans from private companies offering an alternative to original Medicare for health and medication coverage.
4 Tips for Prior Authorization Success
Prior authorizations (prior auths or PAs) are a cost management tool utilized by insurance companies. PAs increase administrative costs for HCPs and create a healthcare obstacle for patients. HCPs depend on prior authorization approvals and insurance payments to remain in business. Healthcare providers (HCPs) must master a productive prior authorization workflow to improve productivity and revenue.
An Essential Guide to Step Therapy
Health insurance companies increasingly employ cost management strategies as more expensive, specialized drugs enter the market. The use of step therapy is one of these cost-control strategies. The goal of step therapy is for patients to try low-cost medications before moving on to more costly ones.
Will Prescriber “Gold Cards” Solve the Prior Authorization Problem?
Imagine a world with fewer prior authorizations. A new Texas law aims to make this dream a reality. House Bill 3459(HB 3459), or the “Gold Card Act,” grants prescribers a “continuous prior authorization exemption” if they have a 90% approval rating on previous authorization requests.
The Players of Prior Authorization
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.
Summary: Help Process Insurance Claims and Payments
Handling insurance claims and processing insurance are important functions within the pharmacy. There are roles dedicated to dealing with insurance claims, payer policy, and prior authorization. Dr. Amanda DeMarzo, PharmD, MBA, PACS is the Associate Director, Patient Access with the National Board of Prior Authorization Specialists. She encourages enhancing patient access through education and certification. […]
