How to help patients with prior authorization

In this article:

• What is prior authorization?
• Common scenarios and reasons for prior authorization
• How to explain prior authorization to patients
• How to streamline prior authorizations
• Bottom line: You can advocate for your patients

In this article

• What is prior authorization?
• Common scenarios and reasons for prior authorization
• How to explain prior authorization to patients
• How to streamline prior authorizations
• Bottom line: You can advocate for your patients

Many patients arrive at the pharmacy ready to pick up their medication only to find out their prescription needs prior authorization, which can lead to frustration and confusion. Insurance companies use prior authorization to manage costs and ensure a procedure or medication is safe and appropriate for a patient. However, the process can often delay treatment, creating a hassle for patients and additional work for healthcare providers and pharmacy staff.

While you might be aware of what goes into a prior authorization and how it can be disruptive for everyone involved, your patients may need help understanding what’s going on behind the scenes. Educating patients on the purpose and process of prior authorization can be a typical part of a pharmacist’s daily responsibilities. In many cases, you can demystify this confusing part of getting prescriptions filled. Read on to learn strategies to explain this hurdle to patients and expedite the process.

What is prior authorization?

Prior authorization is an insurance process in which healthcare providers must obtain approval from a patient’s insurance company before administering certain medications, treatments, or procedures. This protocol ensures that the prescribed care is covered under the patient’s insurance plan and is medically necessary. Insurance companies use prior authorization to manage expenses by avoiding unnecessary procedures and ensuring the most cost-effective care is delivered.

The practice can also promote patient safety by requiring a thorough review of the patient’s history and current medications to prevent potentially dangerous drug interactions or redundant therapies. While prior authorizations can create delays in patient care, their intent is to safeguard the patient while managing costs.

As patients typically discover prior authorizations at the pharmacy, pharmacists may often find themselves in a position to explain the reasons and requirements for prior authorizations to patients. In many cases, they may bear the brunt of the frustration of patients not getting their medication right then and there.

 Prior authorization steps

The process for getting prior authorization can involve various steps that you may want to explain to patients. Here’s a breakdown of the potential steps that may have to be completed:

• Evaluate the medication: The pharmacist checks if the prescription requires prior authorization before processing.
• Notify the healthcare provider: The pharmacist faxes, messages, or calls in a notice to the healthcare provider that prior authorization is required before the prescribed medication can be covered.
• Contact insurance: The healthcare provider contacts the patient’s insurance company to initiate the authorization request.
• Submit documentation: Required medical justifications and supporting documents are sent to the insurer by the healthcare provider.
• Follow-up: The healthcare provider can follow up with the insurer to track the status of the authorization request.
• Communicate with the patient: The patient can ask about the progress of the prior authorization. Sometimes, the insurer may have additional requirements or request that alternative treatments be considered.
• Finalize the process: Once approval is granted, the pharmacist can process the prescription. If denied, the patient can discuss the next steps with the healthcare provider, such as appealing the decision or considering different medication options.

While the prescribing healthcare provider is responsible for taking care of the prior authorization with the insurance company, pharmacists can proactively communicate with patients about what the process entails and notify the healthcare provider to advocate for patients.

Common scenarios and reasons for prior authorization

Prior authorization can be a complex process, but there are common scenarios when prior authorization may be required. These circumstances often involve new medications, insurance coverage changes, or specialized treatment regimens.

New medications

Prior authorization may be required if patients are prescribed new medications, especially those that are costly or not widely used. Insurance companies often require prior authorization to confirm a drug’s necessity and ensure it aligns with the insurance plan’s formulary. The insurer may want to verify that potentially lower-cost alternatives have been considered, which may help reduce costs for the patient and the insurer.

Change in insurance coverage

A change in insurance coverage can prompt a review of the patient’s ongoing prescriptions. Insurers may have different formularies or coverage rules, leading to prior authorization to continue medications under a new policy. In some cases, patients who have been getting refills for a chronic medication may discover that their medication needs prior authorization after some time.

Specialty drugs

Specialized treatments, such as those for cancer or chronic conditions, often involve expensive or complex medications. Insurers require prior authorization in these cases to verify that the treatment is medically necessary and supported by clinical guidelines. In some cases, they may require that step therapy is used in which the patient attempts treatment with other, established medications first before starting a more expensive, newer, or more complex drug. This step is meant to save on costs and ensure care is aligned with evidence-based protocols.

How to explain prior authorization to patients

When helping patients understand prior authorizations, you’ll want to communicate the purpose and process clearly and straightforwardly to help them grasp their importance in their healthcare journey.

Seek first to understand

Before explaining prior authorizations, assess the patient’s current knowledge. Ask questions to gauge their understanding and listen attentively to their concerns. This helps guide the conversation and address their specific uncertainties about the prior authorization process.

Explain the process

After assessing what they might already know, start explaining that prior authorization is a process in which their insurance company needs to approve certain medications before coverage is provided. Tell them it’s an extra step their insurance company requires before they can cover their medication. The prior authorization process can come with potential wait times and additional steps that may need to be taken.

Manage expectations

Patients may need to be aware that the prior authorization process can take time and doesn’t guarantee coverage. Let them know that, while you may have already notified their healthcare provider, they may still need to wait until their healthcare provider sends documentation to the insurance company. The insurance company will then have to review the documentation before they can approve it. The insurance company’s review may result in different outcomes, including requests for alternative treatments or additional information, which could delay the process.

Advocate for and empower the patient

Reassure patients that, as their pharmacist, you’re advocating for their healthcare needs. Inform them you’ll work closely with their healthcare providers to submit the necessary documentation and follow up with the insurance company. You can also let them know that they may be able to speed up the process by contacting their healthcare provider to ensure they’re aware of the situation.

Knowing the ins and outs of prior authorizations is just one part of the process. You might know prior authorizations like the back of your hand, but if your patient remains confused and frustrated, you may need to reassure them and help clarify any misunderstandings.

How to streamline prior authorizations

As a pharmacist, you can help make the process seamless and more efficient in various ways. By incorporating efficient workflows, you can help reduce delays and improve patient care.

Stay up-to-date

Pharmacists should regularly stay up-to-date on insurance formularies and prior authorization requirements. Knowing the policies may help you advise patients accurately. For example, you can subscribe to updates from insurance providers, sign up for updates from the Centers for Medicare and Medicaid Services, and connect with professional networks. By doing so, you can prepare for potential hurdles in advance, which might help you better communicate and shorten patient wait time.

Have a workflow in place

If your pharmacy doesn’t already have a specific workflow, you can often streamline and improve the process for submitting a prior authorization. That might mean having prior authorization request templates ready to send to healthcare providers. Training pharmacy staff and teaching them about the process can also help streamline the workflow and minimize delays in patient treatment.

Build relationships with healthcare providers

Having a good working relationship with healthcare providers can make the process easier. For example, regularly communicating with healthcare providers to coordinate care may be helpful in building relationships. With a shared understanding of helping the patient get timely treatment, pharmacists and prescribers can work together to prevent any lapses in communication with the patient.

Bottom line: You can advocate for your patients

When assisting patients with the prior authorization process, pharmacists help bridge the gap between healthcare providers, insurance companies, and patients. They educate patients who may be confused, advocate for the patient by following up on authorization requests, and empower the patient to request progress updates.

Prior authorizations are often necessary to ensure the prescribed medication aligns with the patient’s insurance coverage. However, they shouldn’t impede necessary treatment. It’s all about finding a balance that safeguards patient health while fulfilling the requirements for insurance coverage.