Managed Care

Create a Process to Expedite Prior Authorizations

Harvey Richman, OD, FAAO, FCOVD, Diplomate ABO

June 22, 2016

SYNOPSIS

New computer programs can speed medications to patients and eliminate wasted staff time. Compute the savings in time and the benefits in service.

ACTION POINTS

DEVELOP & IMPLEMENT A SYSTEM. Once the request comes in, the doctor can log into prior authorization software, and start the process of getting the PA.

GAUGE ROI. A technology solution to facilitate prior authorizations can cut processing time by as much as 70 percent.

EDUCATE PATIENTS. Patients need to know that prior authorizations are required for many medications, and that, despite your in-office speed, delays sometimes occur.

Any healthcare provider today has requests for pharmaceutical prior authorizations from patient health insurance plans to process every week, if not every day. My office has a system in place, backed up by on-call live support, to make sure the process is as fast and efficient as possible.

Prior authorization (PA) is a requirement that physicians obtain approval from their patients’ health insurance plan to prescribe a specific medication for them. For the insurance company, a PA is a process for minimizing costs and ensuring appropriate care, wherein benefits are only paid if the therapeutic choice has been pre-approved by the insurance company.

The Affordable Care Act has had a marked impact on the requirement of getting a prior authorization for medications?. To provide services to a greater number of people for a reduced fee, the plans have implemented smaller drug formularies, and therefore, have forced physicians to jump through more hoops to get the appropriate medications for their patients.

Develop & Implement a System

In our office, we are notified either by our prescribing software, or by a FAX from a pharmacy, that a patient needs a prior authorization. Once the request comes in, the doctor typically logs into our prior authorization software, PARx, and starts the process of getting the PA.

Prior to PARx, we would spend 15-20 minutes alone waiting for someone to answer at the insurance company’s delegate, speaking to a receptionist, followed by getting transferred to a pharmacy tech, and finally speaking with a pharmacist to answer questions (2-3 times) about the medications that we prescribed and why they were needed. The entire process could mean up to an hour of hold time interspersed with conversations that didn’t produce quick results. We did have the option of sending in a FAX request for prior authorization also, but the response times on those were often days, and many patients needed the medications within the day. The technology advances through PARx, and other online options, has made this process much simpler with greater positive responses.

For example, the PARx submission process takes about five minutes; after which, if follow-up is needed with the insurance company, the PARx customer support team takes care of it. Using the PARx system, we usually receive a response to the PA submission within 24-48 hours.

Gauge Cost & Benefit of System & Technology

None of the prior authorization web sites, including PARx, charge fees, either yearly or per use. Our prescribing software, Allscripts Deluxe, which does integrate a form-only prior authorization option, charges a monthly per-provider fee of $25 per month. I don’t use the integrated software program because it is not as intuitive as PARx.

The primary benefit of using PARx is savings in time, cutting prior authorizations process by 70 percent. This frees up my staff to otherwise serve patients; my practice doesn’t have a dispensary, but for other practices, this could include selling in their optical, or processing contact lens and eyewear orders. Faster prior authorizations also means patients get their insurance benefits processed more swiftly, making their interactions with our office faster and more pleasant.

Little-to-No Staff Training Necessary

The PARx system is so intuitive that once the staff member logs on, the program walks them through the process to complete the required appropriate information. The doctor simply needs to have the appropriate history, diagnosis and treatment protocol delineated in the patient’s record.

Educate Patients

Patients need to know that prior authorizations are required for many medications. They also need to be aware of the time delays that are inherent in the process. Lastly, patients also should know that, even with the prior authorization request and quality justification by the physician, the insurance company can still deny.

Harvey Richman, OD, FAAO, FCOVD, Diplomate ABO, is the owner of Shore Family Eyecare in Manasquan, N.J. To contact:drrichman@lowvision-nj.com

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