Efficiently Handling Prescription Prior Authorizations for a Medical Practice
In the article, we will discuss what prior authorizations are and the reasons why a medical practice would need to work on them for patients.
The article explains that there are many different reasons why a medication would require a prior authorization. Typically, it comes down to cost, how often it needs to be used, and how it’s classified under a patient’s insurance coverage. There are different tiers of prescription coverage, and depending on the tier, it will dictate what needs to be done in order to obtain the medication.
In the past, this process was done by hand or over the phone. Now, there are portals that help medical offices enter the information electronically. CoverMyMeds is one of the most popular portals used.
Specialty drugs turn a routine prescription authorization into a clinical submission. Rheumatology practices submit these constantly, because biologics and targeted synthetic DMARDs almost always sit on a specialty tier requiring documented disease activity scores, prior therapy history, tuberculosis screening results, and in many cases, failure of a preferred agent before the plan will approve. Those requests also route to a specialty pharmacy rather than the patient’s retail pharmacy, adding a handoff where approvals get lost. Managing that pipeline as a clinical workflow rather than a form-filling task is where rheumatology billing services earn their keep, and it keeps patients from waiting weeks between the decision to treat and the first dose.
Once a medication is sent to the pharmacy and it requires a prior authorization, the pharmacy will send a notification to the doctor’s office. The office will then complete a form specific to that insurance company and medication. The information that’s typically required includes: patient demographics, insurance information, medication name, dosage, directions, quantity, and whether the patient has ever taken the medication before.
The prescriber also needs to sign the application. Once the form is submitted, the office waits for a decision from the insurance company. If the medication is approved, the pharmacy will be notified. The medical office should then confirm with the pharmacy that they received the approval.
If the medication is denied, the office will need to go back to the prescribing doctor or provider to determine the next course of action.
This concludes with a warning to patients that even if the insurance approves the medication, it doesn’t necessarily mean it will be affordable. Patients often experience sticker shock after waiting for approval, so it’s important to warn them beforehand.
