December 16, 2020
Burdensome administrative tasks are part and parcel of running a small business. But most tasks can be smoothly incorporated into the pharmacy’s schedule without disrupting patient care or pharmacy operations. You can carve out time for accounting and billing, but prior authorizations can arrive at any moment and interrupt filling, counseling, or any other number of important activities, which makes them particularly exasperating.
“Just the mention of the words “prior authorization” seems to put my staff into a stress coma!” exclaimed Tom Bragdon, owner of Pioneer Drug in Newman, California. Bragdon estimates that 10 percent of total new prescriptions require a prior authorization, and there’s usually a jump at the new year and when patients switch insurance. And the process varies considerably among prescribers and insurance, with resolution coming in as little as one hour to as much as several weeks, he said.
Prior authorizations are not a new burden for pharmacies, but according to pharmacists, the number of these administrative annoyances keeps growing. As more specialty medications enter the market, as formularies narrow, and as insurance companies vertically integrate, prior authorizations only become more common. For many pharmacies, prior authorizations pop up as much as five times a day. And that takes a toll on pharmacy staff and operations. “Prior authorizations are extremely burdensome on the pharmacy staff taking time to process, receive an electronic reject, write up a request, send to the physician’s office, and follow up,” Bragdon said.
At Palace Drug in Mammoth Spring, Arkansas, the time spent on prior authorizations accumulates to up to an hour each day. “It causes problems in workflow and leads to unhappy customers,” said M.J. Clark, pharmacy director of Palace Drug.
Besides the disruption to workflow, prior authorizations can cause real problems for patients if they have to go several days or weeks without their medication. And at some point during the process, the pharmacy might lose a patient due to frustration.
Between insurance, the patient, and the prescriber, controlling prior authorizations is only partly in the hands of the pharmacy, but there are a few ways you can help streamline the process and keep patients happy.
Imagine coming into your preferred community pharmacy to pick up your medication only to be told it not only isn’t ready, but it may take a couple of days before the pharmacy is allowed to dispense it. And actually, insurance may require you to get a different medication altogether. You hear the terms “authorization” and “rejection,” even though your doctor has already authorized it. For patients, who expected to grab their medication and be on their way, this conversation understandably causes frustration, and confusion.
“Patients don’t understand a lot of times when you tell them they need an authorization,” Clark said. “They’re like, “Well my doctor prescribed it, why isn’t that authorization enough?” They don’t understand formularies or contracts or anything like that.
The frustration and confusion can result in a patient abandoning a therapy altogether, and potentially abandoning the pharmacy. That’s why it is so important for the pharmacy to have a consistent, effective way of explaining prior authorizations to patients to help them understand and to put them at ease. “Communication at the end of the day is key,” Clark said. “That way everyone at least knows the goal is trying to be accomplished.”
Hannah Bors, pharmacy manager of Oswald’s Pharmacy in Naperville, Illinois, makes sure the patient is the first person she takes care of in the case of an authorization, spending as much time as needed to explain the situation to them. Bors used to work for a national chain pharmacy, and pharmacists there did not have the kind of time to spend with patients as she now has working at an independent. She’s found giving them one-on-one time makes all the difference. “One of the big differences between us and the chains is that we really value customer service and taking more time to contact patients and keep them in the loop and actually have the time to spend with them on the phone,” she said.
However, offering a clear explanation doesn’t guarantee the patient will understand or accept the roadblock with a good attitude. Sometimes, they simply don’t get it. “Oftentimes patients don’t understand even after we’ve explained it to them,” she said. In those cases, they may give up on the process altogether. “We don’t want patients abandoning therapies. We obviously want them to come to our store, too. We know it’s frustrating and people don’t always realize it’s not really in the pharmacy’s control. But we do try to help them out with it.”
After explaining the prior authorization, Bors lets the patient know the cash price in case they want to purchase it without having to go through insurance. Likewise, Bragdon has sometimes found the difference between an insurance copay and a cash price to be negligible, making it an easy solution for the patient to completely circumvent the prior authorization process, though this does not happen very often. If the patient does want to go through insurance, Bors will ask if they want to contact their doctor and ask them to send over the prior authorization approval request, which she says usually expedites the process.
A large part of the responsibility in resolving prior authorizations lands on the shoulders of prescribers. Prescriber responses vary widely: some are quick to respond, but others will completely neglect the process. “Sometimes doctors aren’t great at following through with it. Sometimes they just won’t do it,” Bors said.
Clark and Bors have found some success using an electronic software solution called CoverMyMeds. CoverMyMeds helps by serving as a consistent, electronic platform between pharmacy and prescriber. It can streamline part of the work by pre-populating most of the information fields to cut down on input data. It also alerts the prescriber when a prior authorization has been requested or rejected, and a team member from CoverMyMeds will even follow up with a phone call if it has been a couple of days. “I do feel like it helps,” Clark said. “I think the doctor’s offices that use CoverMyMeds are probably faster, the prior authorizations get done.”
However, not all physicians prioritize prior authorizations even if they have the software. Whenever Clark submits an electronic request, he also faxes one. Some physicians seem to check their faxes more often than their electronic requests, he said. He will often just call the physician directly and simply ask what the most helpful approach would be for them. After making the request, he will always follow up within 24 hours. He emphasized the importance of following up with the nurses, who usually do most of the heavy lifting for the prescribers on getting prior authorizations done.
When prescribers don’t do their part, Bragdon has seen the process take up to several weeks. Or sometimes circumstances extend the waiting period for the patient, such as getting the authorization on a Friday and having to wait the whole weekend before anyone gets around to addressing it. One of Bragdon’s solutions is to process a three-day supply of the medication while the prescriber addresses the request, if insurance allows.
Sometimes this works, sometimes it doesn’t, but it is one strategy to try to bridge the gap.
Clark estimates that about half of the time his team ends up recommending an alternative therapy. But one of the biggest hassles in his experience is trying to figure out what exactly insurance wants. Sometimes insurance will clearly give the alternatives; other times, they won’t. Looking up the state Medicare Part D formulary can be cumbersome. Calling the insurance company is a last ditch option, because you end up waiting on hold for thirty minutes to an hour. This is where Clark’s software system, PioneerRx, comes in handy. It has a function that lists alternatives that insurance prefers, and it allows you to send the change right there in the system.
Even though finding alternative medications may take some work, recommending alternatives can often be the most efficient approach—by going with a drug that has already been approved, it avoids the prior authorization process altogether. Getting there requires buy-in from the patient and the prescriber, however, so the success rate will vary depending on who is involved.
This article was published in our quarterly print magazine, which covers relevant topics in greater depth featuring leading experts in the industry. Subscribe to receive the quarterly print issue in your mailbox. All registered independent pharmacies in the U.S. are eligible to receive a free subscription.
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