Taking the Lead on Prior Authorizations

By Jason Poquette, R.Ph |

Pharmacies have a unique opportunity to lower drug costs, increase revenue and improve the patient experience

Prior authorizations (PA) have long been a source of consternation across the healthcare continuum. They can be time consuming, costly and, some have argued, an obstacle to delivering high-quality care.1 And there is no indication that they are going away any time soon. On the contrary, one study found that the volume of PAs is increasing by 20 percent year over year,2 while another indicates that, in a recent six-year period, the percentage of drugs requiring a PA nearly tripled.3

Despite their dubious reputation, PAs actually present an opportunity for pharmacies. By taking a lead role and actively managing the PA process through the four steps outlined below, a pharmacy can reduce costs, increase revenue, improve provider relationships and, most importantly, ensure better care while enhancing patient satisfaction.


1. Identifying PA Prescriptions.

Pharmacies are under increased pressure to fill more prescriptions faster than ever, so those requiring a PA are often delayed in favor of those that can be processed more quickly. With a simple computer workflow solution, a pharmacy can identify and organize every PA prescription it encounters. The software can generate a one-page summary of relevant data along with a flowchart to ensure the pharmacy follows every appropriate step to maximize the potential for quick approval. It gives staff a single, organized record that they can reference throughout the process and then consolidate into a single spreadsheet for future needs.


2. Connecting Stakeholders through Stronger Communication.

Effectively communicating with stakeholders is absolutely critical to maximizing the potential of PA management. It involves working with each individual provider office to identify the proper contact person(s), and then interacting with them through a customized communication in their preferred channel—fax, email, phone, etc. The workflow solution should support this with pre-designed forms and other materials. For example, sometimes an approved prescription must be handled by an alternative specialty pharmacy. A pre-printed transfer form, which can be faxed with the prescription and patient demographics, enables the pharmacy to simplify this process while documenting procedures at the same time.


3. Thorough Follow-up.

Patients are often unfamiliar with PAs and what they entail. They are used to bringing a prescription to a pharmacy, having it filled, and taking it home. It is important for them to understand when a medication requires special approval, and that the pharmacy will work with their provider and health plan to ensure they receive the most appropriate therapy. These patient communications should be documented, and may need to continue throughout the waiting period while PA forms are being completed and considered by the health plan.

The pharmacy can also follow up accordingly with the health plan about the status of a PA and communicate relevant information back to the patient and provider. While this can expedite approvals, it may involve requesting documents and ensuring that the right forms have been completed. It is therefore important to maintain good records. Similarly, the pharmacy can play a role in decreasing PA denials by suggesting approved alternative medications or first-line options and/or providing the health plan with diagnostic data or lab tests.

In some cases, follow-up means regularly communicating with the patient to identify financial resources to assist with co-pays. The pharmacy can also play a pivotal role in alerting patients to manufacturer-sponsored training resources and educational material.


4. Staff Training.

Managing PAs better also means managing them differently. It is crucial to take a measured approach and provide staff with extensive training and communication. Team meetings, emails and in-store signage are effective ways to support such empowerment. The pharmacy can also deploy its new procedures incrementally by starting with one practice, prescription or disease type and then expanding to others as staff comfort and proficiency increase. In the same way, the pharmacy may begin by training just one or two staff members and then adding others after assessing the program’s initial impact and total volume of PA opportunities.

While managing PAs holds tremendous promise for pharmacies, the reality is that most are already overburdened with excessive workloads and limited resources. To compensate, many have chosen to work with a pharmacy consultant team. In effect, the consultant will administer and manage each of the aforementioned steps—and more—to maximize opportunities and ensure optimal return on investment.

As pharmacies seek new and innovative ways to gain a competitive advantage, taking the lead in PA management can unlock new possibilities. It places the pharmacy in the unique position of being able to increase revenue and control costs while serving as the facilitator of increased collaboration among patients, providers and health plans. It is a chance for the pharmacy to shine as it transforms PAs from a burden into an opportunity to ensure that patients receive maximum benefit from the medications they are prescribed. And that, in turn, benefits everyone.

1. Bendix, Jennifer, MA. “The Prior Authorization Predicament.” Medical Economics. 8 July 2014. Available online at http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/insurance-companies/prior-authorization-predicament?page=full. Accessed 14 July 2017.
2. Cover My Meds. “ePA National Adoption Scorecard.” October 2015. Available online at https://epascorecard.covermymeds.com/. Accessed 14 July 2017. 
3. The Henry J. Kaiser Foundation. “Medicare Part D Prescription Drug Plans: The Marketplace in 2013 and Key Trends, 2006-2013.” 11 December 2013. Available online at http://www.kff.org/medicare/issue-brief/medicare-part-d-prescription-drug-plans-the-marketplace-in-2013-and-key-trends-2006-2013/. Accessed 14 July 2017.

About the Author

Jason Poquette, R.Ph

Director of Outpatient Pharmacy Program
St. Vincent Hospital
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