The Ins and Outs of Prior Authorizations

Using these five tips may make navigating the world of prior authorizations less of a headache.

By Michael S. Cooper, OD

We are all familiar with prior authorizations (PAs)—the requirements by medication prescription plans to obtain permission to prescribe a specific medication to a specific patient. We also all know that insurance companies are tightening the criteria for PAs, trying to steer our medication choices to generic formulations, requiring stepped therapy (trying a less expensive alternative first before allowing us access to our original selection), or outright denying our preferred choice.

TO THE POINT

Empowering staff, understanding technological changes, and leveraging opportunities presented by industry can ease the burden prior authorizations place on a practice.

I believe that we must fight for what we believe to be the best therapies for our patients. To that end, I offer these five tips for working to obtain the PAs we need on a daily basis to ensure optimal care for our patients.

Tip No. 1: Empower Staff

In our practice, we designate several individuals as “PA specialists,” with the task of taking care of these time-consuming tasks. These special members of our team are crucial, in that they are responsible for providing the meticulous details necessary to gain approval for the medications or procedures we prescribe. On any given day, the job these individuals do allows our patients to adhere better to their doctor’s therapeutic decisions.

Tip No. 2: Utilize PA Software

With all the intricacies of PAs, software can offer a light in the darkness. PA software can free up staff time by taking over some of the legwork needed to, for instance, get the proper documentation to the insurance company or pharmacy benefit manager. Electronic PA (ePA) services can save your staff from spending hours on the phone.

My office uses CoverMyMeds and PARx Solutions for ePAs. They advocate on our behalf to make the process smoother and more efficient.

CoverMyMeds offers several advantages, including the ability to provide the exact forms required by the insurer to get the job completed in a timely fashion. I have heard from many colleagues that they depend on this site, as they have found a heightened success rate as a result of this customization. They provide services to an estimated 700,000 prescribers, and they deal with payers that represent 80% of US prescription volume and 90% of the pharmacy market. In fact, many local pharmacies now send us fax requests with pre-filled demographic data to make submissions even easier for us.

PA submission for PARx Solutions uses a “common” or streamlined form system that captures data for many ophthalmic and nonophthalmic formulations. The process is logical and intuitive, and they provide excellent customer support. Another nice feature is that you can save the demographics for future reference. One distinct difference from CoverMyMeds is the generic form used by PARx for insurance submission. Depending on geographic region, there can be hiccups that delay approval, but I have not encountered this on a consistent basis.

Insurance companies can be another source. Express Scripts (www.express-scripts.com), for example, sends notifications describing the timing for approvals using online versus phone versus snail mail (from 2 to 3 minutes for the former, up to 7 to 10 days for the latter). Similar to PARx and CoverMyMeds, Express Scripts does not charge providers for access to its online system—which makes sense, considering that the company wants us to use its online forms to free up phone line bandwidth.

These systems are all free to doctors at this time. I strongly suggest taking advantage of them while these terms still apply, as no one knows how long this pricing (or lack of pricing) will last. Each one has dedicated personnel to assist offices with their processes, so you can imagine the overhead.

Tip No. 3: Master the Online Game

Like the Wild West, the alternatives are wide and vast. A popular site to check drug prices online is GoodRx (goodrx.com). It is fast and easy, and searches can be done by ZIP code to find up-to-date information. Inquiries to this database can be done from any device at your fingertips, making it very accessible to doctors and patients.

Tip No. 4: Don’t Forget the Cards

Each pharmacy or device company issues coupons or savings card programs for patients. Here’s the rub though: Do patients use them? I have asked local representatives to provide estimates of utilization, and they range from less than 10% to 30% (being generous). A couple of pearls can be used to help patients save and at the same time adhere better to their therapies.

One key protocol we started a couple of years ago was empowering staff members to close their conversations on medication instructions with a discussion of how to activate the coupon cards before heading to the pharmacy. After implementing these discussions, our callbacks with questions have decreased by half.

We also tell all patients to explicitly tell their pharmacists that these cards are secondary insurance to complement their primary insurance carrier. Why is this important? With the advent of electronic prescribing, most pharmacies try to cut down their processing time by closing the claim immediately, which is detrimental to the coupon programs. Our office makes a point to tell patients to raise their voices to ensure they maximize their cost savings at the register.

Tip No. 5: Utilize Superstar Representatives

Across the board, every company has access to a plethora of data to help them understand what is happening in the industry. These companies are continually negotiating and pivoting based on changes to the system. I constantly try to talk to sales representatives about these issues to stay on top of the situation and attempt to avoid being blindsided by changes in coverage gaps, donut holes, and deductibles.

Furthermore, never forget to reach out for samples that can serve as a stopgap for patients who need therapy immediately but may have to wait for days or months for coverage to come through (in extreme situations). This can be especially important for glaucoma patients.

CONCLUSION

Is the system described above for dealing with PAs perfect? No. With that said, what we can do is expend as much effort as possible to ease the process for our practices and our patients. Taking that extra minute to explain these coupon cards to patients can save your office priceless time throughout the day and, more important, help the patient to understand the value of a new therapy and ensure continuity of care.

Michael S. Cooper, OD
• Private practice, Windham Eye Group, Willimantic, Conn.
• financial disclosure: advisory board member and/or consultant and/or speaker bureau member, Alcon Surgical, Allergan, Bausch + Lomb, Bio-Tissue, inVentiv Health, Johnson & Johnson Vision Care, The Mentholatum Company, Shire, and TearScience.
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