What is Prior Authorization?
Prior authorization—sometimes called precertification or prior approval—is a health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage. Prior authorization creates barriers to patient access and approvability of a drug. It can cause barriers to market access as well for pharmaceutical companies. Whether you work as a pharmacist in a specialty setting, or are a nurse or medical administrator at a private practice or ACO, certifying your team as a Prior Authorization Specialist will save you time & money.
Are you a patient access, market access or specialty pharmaceutical sales representative?
Help your doctors, nurses and other healthcare providers improve their approvability and pull through of your products so that you can remove any barriers to patient access and market access for patients. Increase the chances that your product ends up in the hands of patients who need it
Basic Step by Step of the Prior Authorization Process
The pharmacy will contact the doctor if they did not obtain prior authorization from the insurance company when prescribing the medication
The physician will contact the insurance company and submit a formal authorization request
The insurance provider may have the patient fill out and sign more forms which need to be reviewed
The insurance company will alert the pharmacy once they have approved or denied the request
The Prior Authorization is Complicated & Extremely Time Consuming
The prior authorization process can take days and even weeks! Prior Authorizations create obstacles for patient access and can be frustrating for patients who need access to their medications. For pharmaceutical companies, market access is key and helping their doctors navigate the prior authorization process by being certified as prior auth specialists can help improve approvability of a prior auth and pull through. For professionals working in patient access, market access, field reimbursement, speciality pharmacy, or in an outpatient setting, becoming an expert for yourself or your team will help you save time & money!
Why is the prior authorization process complicated & time consuming?
The prior authorization process is time consuming because of the administrative burden to doctors and their staff. A recent study from the American Medical Association showed that prior authorization issues contribute to 92% of delays. A recent survey by the American Medical Association (AMA) found that the number of prior authorization for both prescription and medical services had significantly increased
Areas that a Patient Access professional must be adept include a thorough understanding of the goals of the healthcare system, a comprehensive understanding of the ins and outs of the healthcare system including how it is funded, and how is patient access determined by different payers and what are some of the roadblocks to a patient accessing needed medication. These are just as important as knowing information about your company’s product and how it benefits patients. These are all topics addressed in the PACS program very comprehensively.
What about Expanded Patient Access Programs
Expanded access programs provide access to medications that are still in clinical development to patients who need them who are not enrolled and/or qualified to enroll in a clinical trial. What happens when the drug is approved and it is not on the patient’s formulary? Most likely it will require a prior authorization which can cause a gap in care or sometimes the patient not having access at all to a product they were using for months if not years
Realistically, very few HCPs actually understand the Prior Auth process so if one of a company’s products requires one the HCP is far more likely to switch to a product that doesn’t require one, even if your product would be more effective and safe for the patient and if they see a pattern where it often requires a PA and changing the product, they will refrain from prescribing it all together
Often HCPs think a denial on prior auth is the end of the road, but it isn’t this again comes from a lack of understanding in how to assess the denial and the appeal process
The Prior Authorization Specialist Program is the industry standard for establishing a career in healthcare managed markets
The Certification Prior Authorization Specialist Training is the first of its kind in the World. This course was created by a panel of experts with a range of experience from every role involved in the Prior Authorization Process. This allows for you to gain valuable access to inside knowledge and expertise from provider’s offices, pharmacies and Insurance plans. Becoming Certified will allow you to become an expert in your field, distinguish yourself, and become a leader with tremendous career growth potential
Did You Know?
Certified Healthcare Professionals
The PACS Certification demonstrates that professionals have met rigorous standards through intensive study, self-assessment and evaluation. The PACS certification is the most comprehensive training program in the world. Achieving the PACS demonstrates the highest standards of knowledge, and excellence in the prior authorization field. It also sets the stage for continual professional development through values centered on lifelong learning.
Why Certify for the Prior Authorization Certified Specialist Program?
- Expand your career options
- Increase your earning potential by up to 24%
- Become an expert/leader in prior authorization
- Be on the cutting edge of a rapidly growing and highly in-demand career field
For Specialty Pharmacy
The fastest growing segment of the pharmaceutical industry is specialty pharmacy. By the year 2020, it is estimated that specialty drugs will represent 50% of drug cost reaching an astronomical cost of 400 billion or 9.1% of national health spending for only 2% to 4% of the US population.Future growth trajectories of specialty medications are expected to continue to grow at a very rapid rate.
Because of the rapid increase and demands in the prior authorization field in healthcare, more and more specialty pharmacies are providing the service of submitting prior authorizations on behalf of the providers and patients. It is imperative that the highest level of excellence in training, knowledge and execution of the PA process is attained for their staff.
For Provider Offices
Based on a 27-question survey administered by the American Medical Association, medical practices spend an average of two business days a week per physician on Prior Authorizations. On Average, this translates to 29.1 PA requests per physician per week that take 14.6 hours to process. Approximately half of prior authorization request are for medical services and half for medications. This can cost over $85,000 per year to support a full-time physician. Over 30 percent of practices employ a full-time employee that has dedicated all their time on Prior authorizations
By choosing to certify your staff, you are choosing to make a great investment. You are choosing to educate your staff with the most comprehensive training program in the world. Achieving the PACS demonstrates the highest standards of knowledge, and excellence in the prior authorization field for both medications and medical services
Through educating your staff on this rapidly growing and changing field, you can choose to make a major impact on your practice
There are many people who are involved in initiating the prior authorization requests for the patient that may be admitted in a hospital or has outpatient services. Whether your staff includes, nurses, pharmacists, pharmacy techs, nurse practitioners, physician assistants, case managers, clerical staff, medical assistants, administrators or dedicated prior authorization specialists, the PACS can be beneficial and an investment.
Often, the medical services and medications that require a prior authorization can be very expensive and difficult to achieve. If a prior authorization is denied, and the service has already been given, a Hospital may lose revenue. By properly training your staff with the highest level of standards and knowledge in the PACS program, you are investing in your staff, Hospital and patients
For Insurance Plans (Payers)
It is no secret that the prior authorization field is a highly demanding, changing and growing field. Given the demands of turn around times for processing requests and seasonal variances in requests with enrollees, it becomes challenging for the payer to keep up at times. A health care plan’s quality and performance rating can be reduced when prior authorization requests are not processed in the given time frame. With the wide, seasonal and sometimes unpredictable market changes in prior authorization demands on a health plan, the payer (insurance company) is forced to hire temporary employees or contractors). Often times, the temporary employees have no knowledge or experience in prior authorizations, which can lead to hiring unqualified staff. Many times, this can result in a high turn over rate due to mistakes, slow processing times and inefficiencies.
On average, a temporary or contracted employee will need 4 to 6 weeks of training before starting and may end up only working an additional 3 to 6 months. As a result, health plans lose a substantial amount of money on training, inefficiencies in the process and high turn-over rates of staff. There is also a greater risk of losing quality and performance ratings with unqualified staff.
By choosing to certify your staff, you are choosing to make a great investment. You are choosing to educate your staff with the most comprehensive training program in the world. Achieving the PACS demonstrates the highest standards of knowledge, and excellence in the prior authorization field.
For Pharmaceutical Companies
Nothing can be more challenging to a sales representative who is given a medication in a territory with prior authorization restrictions. Although the physician may prefer his/her product, they many not prescribe it in order to avoid the burden of the PA. By addressing the challenges of the PA, a pharmaceutical company may yield tangible and substantial benefits
Below is an excerpt “Tackling the Prior Authorization Challenge: A Critical Task for Pharma” published May 4, 2017
"For example, a sales representative took over a territory that had severe PA restrictions. While physicians preferred her product, they frequently switched to other formulary drugs to avoid the hassle of prior authorization. At the outset, this territory ranked 141 st in sales out of 150 territories nationally. After introducing practices to a PA service, practices in the territory developed a higher comfort level, knowing that the PA burden was being handled for them. As a result, this representative was able to increase sales while building strong relationships with practices, resulting in a climb to the 6 th ranked territory in the U.S providing their customers with the best PA solution is an effective approach to saving prescriptions and handling one of the most frequent and important barriers to physician prescribing and patient access"
By providing the PACS training to your staff, you are choosing to make a great investment