Healthcare providers today have a range of options when it comes to managing the ever-increasing number of prescription prior authorizations (PA). They may choose to “go it alone” – searching for the correct submission form, completing the form, submitting the completed form and following up with the plan (often by phone). They may opt to use a “form based” third party service to find and complete the correct form, followed by the burden of follow up with the plan falling on practice staff. Or, they may choose a “full service” PA management partner. I’ve referenced PARx Solutions as the premier full-service PA management partner in past blogs; now, let’s consider what “full service” really means, and why should it matter to providers and their patients?
1. Insurance Verification: I was recently at a pharma client sales meeting when a district manager approached me with a concern about our service. She informed me that one of the practices in her district had tried using PASS (PARx Prior Authorization Support System), but that all nine of the PAs submitted were denied due to “insurance not found.” Upon hearing this, I reviewed all of the PA submissions from the practice, and found that just three submissions were placed through PASS – and all three were approved. As it turned out, the nine denied PAs were submitted using a different service.
This unnoticed error isn’t unusual from a busy practice; we have found that nearly half of all PA submissions cite incorrect patient insurance information, often due to including the medical insurance information rather than the prescription plan. As a full-service partner, PARx calls the pharmacy to confirm the patient’s prescription plan coverage prior to submission, to ensure that the PA is routed to the appropriate plan. This in contrast to a form based provider, in which case the PA is submitted to the wrong plan and so denied for insurance not found – as was the case in this example.
2. Follow-up with the Plan: Plans don’t always act expeditiously with regard to PA submissions. Often, practices need to follow up with the plan to get an answer on a previously submitted PA, or to provide additional information. Calling a plan generally results in extremely long telephone hold times (we have found typical hold times ranging from 10 to 45 minutes) before the staff member has the opportunity to speak with anyone at the plan. Most practices cannot dedicate the resources to sit idly on hold, waiting for the plan to respond to their inquiries. With a full service partner, follow up is performed on behalf of the practice, saving significant time for practice staff and resulting in faster PA decisions.
3. Quality of Submission: Plans frequently change the PA requirements for specific medications, as well as the PA submission forms and the process for submissions. This can become confusing for practices and result in more time being spent on the submission process, as well as frequent omissions of key information. Full service PA management partners review all submissions for completeness and accuracy prior to submitting the request to the plan. This results in a higher quality submission, leading to more approvals and better workflow management for the provider.
When considering how best to manage the increasingly complex world of prescription PAs, consider using a full service PA management partner to ensure that more patients receive the medication their provider deems best for their treatment.
Talk with busy physicians and you’ll soon hear about the ever-increasing difficulty in getting approval for the medications that they believe are most appropriate for their patients. For pharma marketers, a superior efficacy, side effect and dosing profile is a necessary start, and a favorable managed care formulary position can be another positive step toward commercial success—but, more and more frequently, a prior authorization (PA) request must be approved before a medication can be dispensed and taken by the patient.