Your long-time psoriasis patient is clearly struggling, but the insurer won’t budge. You and your office staff have spent countless hours filing prior authorization requests (and subsequent appeals) to get the patient on a new biologic drug.
So far, your patient has tried and failed a handful of less expensive treatments, leaving him frustrated, frightened, and even worse—hopeless.
Prior Authorizations By the Numbers
66% of prescriptions rejected at the pharmacy require PA (approximately 300 million PA requests). Of those, 36% are abandoned each year. (CoverMyMeds Analytics, 2017)
40% of providers cite PA around specialty medications as the main pain point when prescribing medication. (CoverMyMeds Specialty Follow Up Survey, 2017)
Every medical dermatologist practicing today likely has a similar story, and for those in solo and non-group practices, the administrative burden associated with prior authorization (PA) and appeals can be even more harrowing and has undoubtedly contributed to growing rates of dermatologist burnout.
Prior authorization is a major, and in some cases an insurmountable, hurdle. A survey of 1,000 practicing physicians by the American Medical Association1 showed that doctors believe these prior authorizations affect clinical outcomes for nine out of 10 patients, and 92 percent said prior authorizations have led to delays in patient care.
Not being listed on a formulary, being listed on a higher tier, cost, and step therapy, or “fail-first” protocols are key reasons for prior authorization denials.
There is no special sauce to getting approvals, but I have come up with a few tips and best practices that can make it easier for us to get our patients the treatments they need.
There is no one-size-fits-all policy. All payers have different formularies and prior authorization procedures. Keep track of the policies and make sure that your staff has access to this fluid document. Update this list regularly to keep pace with any changes.
Lean on the AAD
The American Academy of Dermatology (AAD) highlights several free electronic prior authorization products to help make the process faster and easier. These include:
- This free web-based service does not require integration with EHRs. In fact, EHR isn’t necessary to use the service. Create an account using your NPI and then you or a delegate can use the service to initiate and track PA requests.
- In its own words, CoverMyMeds, “streamlines the medication PA process, electronically connecting providers, pharmacists and plan/PBMs to improve time to therapy and decrease prescription abandonment with electronic prior authorization (ePA).”
What’s more, the AAD also offers a template for prior authorization drug denial letters to payers on their Practice Management Center Website (bit.ly/AADTemplate). There are no guarantees, of course, but using these expert-compiled templates may help to ease some of the burden on doctors.
PRIOR AUTHORIZATION AND EPRESCRIBING
The Standardizing Electronic Prior Authorization for Safe Prescribing Act, (H.R. 4841) introduced in the US Congress in January, is designed to drive ePA usage in the Medicare Part D Program.
Currently, 17 states call for the use of electronic methods for submitting medication PAs, in compliance with the NCPDP SCRIPT Standard (Available online at http://ncpdp.org/NCPDP/media/pdf/NCPDPEprescribing101.pdf)
Efforts to override step therapy will clearly help get patients the medications they need in a more timely fashion. The AAD state policy team is active all year long. To make the most impact, the team needs to know what challenges exist and can benefit from hearing first-hand accounts from practices. Get involved with your state medical society and share any prior authorization horror stories with AAD online (bit.ly/AADSubmitStory) to help their efforts.
Invest in a Smart EHR
Smart e-PA systems can help make sure that all of our Is are dotted and all of our Ts are crossed. An electronic prior authorization module cuts down on re-entering duplicate data, downloading forms, and even using fax machines.
When the process is automated, things tend to go more smoothly, it can be easier to track and monitor progress, and physicians can then send a “clean” prescription to pharmacies.
As stated above, PAs are here to stay. But perhaps not forever. I look forward to the day when technology may offer us genetic profile tests that will accurately predict who will be a responder—or non-responder—to many of the most expensive therapies. Armed with evidence that the patient will benefit from therapy, we could make a more convincing argument to payers. This would be a prior authorization that would actually make sense.