Jun 24, 2024
8 minutes read
Engagement in Prior Authorization: Duties and Training
INTRODUCTION:
The prior authorization (PA) process is critical in providing some patients with their medically necessary products. It is the insurance or payers’ way of controlling costs by approving or denying certain medications, procedures, or devices that may not usually be covered or is on a higher tier on the formulary. It ensures that what the patient receives is medically appropriate for their situation. Each step of the process includes unique roles and responsibilities at the healthcare provider’s (HCP) office, the pharmacy, the payer, or the manufacturer.
THE PHARMACY:
The pharmacy typically is the start of the utilization of the PA. The patient will bring in a prescription prescribed by their prescriber that will alert the requirement of a prior authorization once processed through the patient’s insurance. Prescriptions warranting this type of alert may include specialty medications or glucose monitoring products. The pharmacy then notifies the patient and the prescriber of this request. Sometimes, at specialty pharmacies where most of their products require a PA, pharmacists can directly work with the payer to accelerate this process to receive timely reimbursement and patient access. The responsibilities and education requirements for each role at this step of the PA process are listed below:
THE HCP OFFICE:
Once the provider’s office gets notice of a PA request, they will gather the necessary information to submit to the payer. This process can include patient demographics, charts, labs, and any clinical documentation that will aid in proving the necessity of the medication or service. Retrieving, documenting, and submitting such forms to the payer can be done with the help of the prescriber, medical assistant, clinical documentation specialist, prior authorization specialist, medical coder, or case manager. The responsibilities and education requirements for each role at this level of the PA process are listed below:
THE PAYER:
Finally, this step of the process determines whether the previous roles’ collaborative efforts have been proven successful. At this point, the pharmacy and the provider’s office should have submitted all required documentation to the patient’s health plan or payer. Pharmacy Benefit Managers (PBMs) also play a crucial role in this process, as they manage the pharmacy benefits and prior authorization requirements on behalf of health plans. Prior authorization coordinators, clinical reviewers, medical directors, or utilization management specialists can assess and determine whether the submitted claim will be approved or denied. This is done following the health plan’s formulary or the criteria for a specific medication, device, or procedure being requested. PBMs establish the prior authorization criteria and procedures that health plans use to manage drug utilization and costs. Many plan’s have already or will be implementing artificial intelligence (AI) to aid in this step of the process through obtaining and cross-checking information that previously had been done manually. AI can automate decision-making in simple cases, whereas, in more complicated ones, it can aid in collating the necessary information needed to assist the payer in making a decision. The responsibilities for each role at this level of the PA process are listed below:
THE MANUFACTURER:
Reimbursement and Market Access Teams: Pharmaceutical manufacturers typically have dedicated teams focused on reimbursement and market access. These teams are responsible for understanding the various payer requirements, formulary restrictions, and prior authorization criteria for the manufacturer’s products. They work closely with payers, pharmacy benefit managers (PBMs), and healthcare providers to ensure that patients can access the prescribed medications.
Some of the roles included at the manufacturer’s level include:
THE FINAL DECISION:
The approval or denial is usually sent to the HCP’s office that submitted the PA request; however, it can also be sent to the patient directly. In the case of a denial, an appeal can be made to provide more information that may justify the payer approving the PA. The typical prior authorization process from start to finish can take anywhere from one day up to a month, with payers usually giving a decision in 3 or more days, according to the 2018 American Medical Association (AMA) Prior Authorization Physician Survey. Delays in this process can affect a patient’s access to necessary services or their medication adherence. Each role within the PA process is responsible for improving their knowledge of prior authorizations to increase efficiency and minimize delays. Those looking to advance their knowledge and skills of prior authorizations can obtain certification through the first and only accredited Prior Authorization Certified Specialist (PACS) Program through the Accreditation Council for Medical Affairs (ACMA).
CONCLUSION:
In this article, we have discussed the various responsibilities and educational requirements for each role within the prior authorization timeline. It was determined that each individual must be accountable for their responsibility within the process to get an accurate decision from the payer efficiently. Educational backgrounds for each role was also identified. Overall, increasing one’s knowledge of the prior authorization process as a whole and their role within it can significantly improve delays in therapy and, thus, improve healthcare outcomes.
Kiana Dixson PharmD, BCMAS Shakhzoda Rakhimova PharmDc 2024
References Accreditation Council for Medical Affairs. Prior Authorization Roles: Clinical and Administrative. 2023. Dixson, Kiana. The Pharmacist’s Role in Prior Authorizations. 2022. The Pharmacy Times. https://www.pharmacytimes.com/view/the-pharmacist-s-role-in-prior-authorizations ASHP. Prior Authorization Pharmacy Technician. 2023. https://www.ashp.org/pharmacy-technicians/about-pharmacy-technicians/advanced-pharmacy-technician-roles/prior-authorization-pharmacy-technician ASHP. Medication Access Coordinator. 2020. https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/specialty-pharmacy/Medication-Access-Coordinator.pdf Keough, L. Patient Care Coordinators. 2017. Health Careers Info. https://www.healthcareersinfo.net/patient-care-coordinators/ AMCP. Your Roadmap to a Career in Managed Care Pharmacy. 2023. https://www.amcp.org/resource-center/group-resources/student-pharmacist-center/roadmap-career-managed-care-pharmacy Nurse Practitioner Vs. Physician Assistant: What’s The Difference? | NurseJournal.org. 2022. https://nursejournal.org/resources/np-vs-physician-assistant/ AAMA – What is a Medical Assistant?. 2023. https://www.aama-ntl.org/medical-assisting/what-is-a-medical-assistant Simmons, Liz. How To Become A Case Manager: Salary, Education Requirements And Job Growth. 2023. Forbes. https://www.forbes.com/advisor/education/become-a-case-manager/ Society of Human Resource Management. Medical Coding Specialist. 2020. https://www.shrm.org/resourcesandtools/tools-and-samples/job-descriptions/pages/medical-coding-specialist.aspx Gundersen Health System. Prior Authorization Specialist (DME) | Gundersen Health System. 2023. https://www.gundersenhealth.org/careers/find-a-career/prior-authorization-specialist-dme Clinical Documentation Specialist Job Description | USF Health Online. 2019. https://www.usfhealthonline.com/resources/health-informatics/clinical-documentation-specialist-job-description-and-salary Al-Haque, S., Khanna, V., Mandal, S., Rayasam, M., & Singh, P. AI ushers in next-gen prior authorization in healthcare. 2022. McKinsey & Company. https://www.mckinsey.com/industries/healthcare/our-insights/ai-ushers-in-next-gen-prior-authorization-in-healthcare#/ Human Edge. Referral/Authorization Coordinator. 2023. https://humanedge.com/jobs/job-details/288999/referralauthorization-coordinator Clinical Reviewer Job Description: Salary, Duties, & More. 2022. Climb the Ladder. https://climbtheladder.com/clinical-reviewer/ Kelley, Jordan. What Is Utilization Management In Healthcare?. 2023. https://www.enter.health/post/what-is-utilization-management-in-healthcare Myndshft. The Ultimate Guide to Prior Authorization. 2023. https://www.myndshft.com/the-ultimate-guide-to-prior-authorization/#how-long-does-prior-authorization-take
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