ATLANTA—Obtaining prior authorization to ensure services or prescription drugs are covered by a patient’s health plan consumes staff time, and delays or denials may cause patients to abandon treatment, according to speakers at the 2019 ACR/ARP Annual Meeting. In a session on Nov. 10, the experts shared tips to smooth the process.
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Explore This IssueJanuary 2020
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Train Staff on Rheumatic Diseases
Prior authorization may be required due to quantity limits imposed by health plans on medications, step therapy requirements, to check if medications are excluded from a plan’s formulary or to ensure coverage for high-tier, expensive drugs. Staff training is the first important step, said Jessica Farrell, PharmD, associate professor of pharmacy practice at Albany College of Pharmacy and Health Sciences, New York.
In a 2017 AMA survey of 1,000 practicing physicians, 64% reported they waited at least one business day for prior authorizations from health plans, 23% said they waited three to five business days for these approvals, 86% said time spent on prior authorization processes has increased over the past five years, and 78% reported that prior authorization delays or denials sometimes lead to prescribed treatments being abandoned by their patients.1
Rheumatology practices report significant delays in their patients’ access to treatments due to prior authorizations. One study in Arthritis Care & Research showed that 71% of 225 patients who were prescribed an infusible medication required a prior authorization and waited longer to receive their drug.2 More than 50% of rheumatology providers in the study reported their staffs spent up to 20 hours per week on prior authorizations.
“This can … cause patients to be on higher doses of steroids while they wait, being in flares for longer periods of time, and their diseases being uncontrolled,” Dr. Farrell said. “This hurts patient outcomes.”
Prior Authorization Tips
Dr. Farrell suggested the following:
- Invite a pharmacist or nurse educator to talk about diseases and FDA-approved therapies;
- Train staff on common ICD-10 codes for rheumatic diseases to avoid clerical errors and recognize which codes often flag denials;
- Create a comprehensive list of common medications currently approved for rheumatic diseases. Infusible medications may have different dosing regimens for each indication, so a plan may deny coverage due to the wrong dosing regimen; and
- For new staff, develop standardized work flows that include steps for prior authorizations to be reviewed by someone experienced in the process.
“Identify specific staff to handle certain prior authorizations, such as for infusibles, so they learn the process,” Dr. Farrell said. “They’ll develop their own tips and tricks and become more efficient.”
Some electronic health record (EHR) systems include patient profiles with such details as medical history and past medication failures, so benefit investigations or appeals following coverage denials are easier to perform than in the past, said Dr. Farrell. EHRs may include calendars that show when a patient’s drug prior authorization will expire and needs to be renewed.
If coverage is denied, request an expedited appeal. Review denial letters to pinpoint the payer’s rationale, then respond with a letter that includes the patient’s medical history, past medication failures and evidence, such as abstracts, to support the requested therapy or as justification for off-label use. “If you get to a peer-to-peer review step of an appeal, you can also ask for a rheumatologist to review it. Many plans have specialists on staff who understand our disease states,” said Dr. Farrell.