Prior Authorization Denied, Now What?

If you think obtaining a prior authorization (PA) is a dreadful task, what happens when the submission is denied? Sure, you could throw your hands up and say you did what you could for the patient, but health care is about helping patients, right?

Countless new drug therapies are in development and coming to market, and more than half are biologics or specialty medications. Biologic coordinators can help bridge the gap between you—the clinician prescribing therapy—and your patients receiving specialty medications.

WHAT EXACTLY IS A BIOLOGIC COORDINATOR?

The title biologic coordinator is relatively new, but the popularity of this position has grown during the past 5 years. Many of these professionals grew into the role organically. A knowledgeable, detail-oriented, and organized member of your staff who is willing to fight for patients just might be the right person to designate as your practice’s biologic coordinator.

One of the many ways a biologic coordinator could help you in the office is by assisting with the appeals process. A coordinator’s value lies in their ability to work closely with manufacturers on their enrollment forms and submit them properly. Knowing how to receive drug approvals is an integral part of a biologic coordinator’s job. This is where they best serve the global good of the practice, the prescriber, and the patient.

DEALING WITH LEAVE BEHINDS AND APPEALS

When a staff member from a dermatology office contacts the pharmacy and sends in a prescription, the pharmacy assists in the PA process and even prepares an appeal. Because of low staffing, high turnover, and overworked prescribers, however, the appeal may never be submitted. With some bridge or free drug programs, if an appeal is not submitted within 90 days, the patient ceases to receive therapy. Leave behinds are PAs that are left on the table, and they are a lose-lose situation for everyone involved but mostly for the patient, because up to 65% of denied claims are never resubmitted.¹

A significant number of initiated PAs that are denied or left behind and never addressed can be attributed to a poor understanding of the appeals process, understaffing, time allocation, and other physician burdens associated with the PA process. Insurance company formularies, step edits, and drug exclusions are the apocalypse, according to most physicians I know—the end of the prescriptions and the beginning of “suggestions.” It requires a constant effort for biologic coordinators to stay on top of pharmacy benefit managers and payer changes. Fortunately, there may be no one in the industry more dedicated to their patients than a biologic coordinator or patient advocate.

One of the first steps after receiving a denied PA is to notify the manufacturer. Free drug programs are intended to provide therapy and relief to patients while the process unfolds and an appeal is conducted. The notification also engages the field reimbursement manager or field reimbursement access specialist in the case to track, monitor, and assist the office with the process. This unique position is underutilized by medical offices and may be one of the most valuable assets for biologic coordinators when there is a difficult case.

Knowledge Share

One thing that differentiates a biologic coordinator from another health care professional in the office is the former’s ability to provide valuable input and assistance to the prescriber or doctor in the appeals process. Biologic coordinators are well versed in and knowledgeable on the specific drug criteria required to gain access to a specialty medication. Every medication has a certain recipe to bake the cake, if you will. Biologic coordinators mix the ingredients, set the temperature, and determine when it is done. They know the ingredients that can get you a positive outcome or approval for your patient, the clinic, and the manufacturer.

A simple recipe is knowing that certain criteria must be tried and fail for a payer to approve a medication. For example, to get a drug approved, a patient must try and experience failure with two midpotency topical corticosteroids and a topical calcineurin inhibitor. Then, a rationale must be provided by the prescriber for why light therapy is not appropriate for the patient. Never mind the $40 copay, $6 gallon of gas, and time lost from work 3 days per week for a treatment that is not FDA approved for eczema.

The Physician’s Right Hand

Collaboration between a prescriber and a biologic coordinator can serve a patient best. To quote my physician, Neal Bhatia, MD, chief medical editor of Practical Dermatology® magazine, “A medical assistant sees the problem. A biologic coordinator sees through the problem to get to the solution.”

A biologic coordinator is a valuable problem-solver—someone who can work closely with the doctor or prescriber and help with the appeals process. Yes, the prescriber must submit the PA and appeal, but a biologic coordinator can help in multiple ways.

For instance, when I receive a PA denial, Dr. Bhatia and I discuss the case and come up with a plan together that suits the patient and their specific needs. I then research the reasons behind the denial and use my experience to address each bullet point; I add supplemental notes to provide a rationale for why a specific step therapy may not be appropriate for the patient. The directive ultimately comes from Dr. Bhatia, but as a biologic coordinator, I am experienced enough to help prepare the appeal for him to approve. Besides, Dr. Bhatia tends to use more expletives in his descriptions than I do, so I usually review the appeal before it gets sent out anyway.

I also find it helpful to have the patient write a short paragraph describing how their disease state affects them personally and professionally. This supplemental documentation can go a long way. The long-winded explanations coming from my office may not inspire much empathy in the clinical pharmacist. When, however, they hear directly from the patient about the endless scratching, the consistent changing of bed sheets, and the need to vacuum the house throughout the day because of shedding skin, it is hard for them not to reverse the determination.

CONSIDER APPOINTING A BIOLOGIC COORDINATOR

The drug approval process relies heavily on the knowledge, experience, and compassion of the biologic coordinator. It is up to these professionals to ensure that patients receive the therapy they need so that they can enjoy the quality of life that other people often take for granted.

1. Strategic denials management: the key to an efficient revenue cycle. RevSpring blog. June 13, 2018. Accessed January 29, 2023. https://revspringinc.com/resources/blog/strategic-denials-management-the-key-to-an-efficient-revenue-cycle