The Pharmacist’s Role in Prior Authorizations

Drug pricing and reimbursement is a complex process that has been shrouded in mystery. Many stakeholders in health care do not necessarily understand the underlying mechanisms that drive pricing and formulary coverage.

In the past few years, many states have sought to increase drug pricing transparency through legislative means. Additionally, with the rise of more specialty products, biologics, and biosimilars, prior authorizations (PAs) continue to increase. Indeed, the PA process often involves complex transactions and increases the burden not only on physicians and pharmacies, but also impacts patient access.

According to a 2020 survey conducted by the American Medical Association, PA issues contribute to 94% of care delays. Eighty percent of physicians surveyed reported that PAs led to patients abandoning their recommended treatment. To increase patient access to treatment and other patient outcomes, the health care system must streamline this process with a standard baseline of knowledge and understanding of PAs and all players involved in the stages.

With nearly half of physicians expressing the need for a staff who works exclusively on PAs, there is an urgent need for medical and ancillary health care professionals who are specialized in PAs. It is often at the pharmacy counter where patients are unable to fill their prescriptions due to PA challenges. Pharmacy technicians can play an important role in helping to process PAs for patients to help streamline access to their medications.

PAs and Reimbursement: What is it?

PA is a process used to decide whether a prescribed device, procedure, service, or medication will be covered and paid for. This process originated because of the changing landscape of insurance coverage over the years.

In the 1960s, there was a noticeable misuse of the review processes for admissions because there was a rise in the number of people visiting their local hospitals. Physicians would perform utilization reviews by looking at admissions and then personally make the decision for the claim.

PAs are currently performed by specialists for the purpose of minimizing unnecessary payer spending. The goals of a PA are to decrease health care costs by avoiding expensive options, guarantee safety, and improve patient outcomes

The authorization process is a unique area of medicine and combines clerical work, clinical knowledge, and finance into a single service. To succeed in processing PAs, there must be an understanding of health care system codes (ICD, HCPCS, etc), insurance policies, and compliance regulations.

A physician assesses and prescribes care for a patient, but the payer must agree with the plan of action. Generally, pharmacists and pharmacy technicians process medication PAs, whereas physicians and nurses process service line PAs.

Pharmacists as PA Specialists

Pharmacists can be seen working in the authorization process on the community pharmacy side or the intake, payer side.

On the pharmacy side, pharmacists may:

• Work with the prescribing physician’s staff to process a prescription.
• Communicate updates to the patient.
• Communicate with the prescriber’s office and/or the payer to help process the request if a payer denial occurs.

On the intake side, pharmacists (specialty pharmacists in particular):

• Review PA request that are sent to a payer.
• Ensure information is properly documented so that a decision can be made.
• Speak with the prescriber’s office to obtain missing clinical information.

Pharmacists with specialized knowledge in PA may also consider opportunities with payers, pharmacy benefit managers, and pharmaceutical companies. Indeed, drug manufacturers have growing field reimbursement teams as well as health economic outcomes research teams that are playing an increasingly important role in drug pricing and reimbursement.

A PA specialist:

• May oversee incoming patient order process.
• Collect vital documents and contact the physician’s office for additional information.
• Determine whether the order is likely to be approved (pre-pre-authorization).
• Complete payment approval from insurance, Medicare, and/or Medicaid prior to scheduling order.

Specialized Training for PA Specialists

With the rising demand in specialized knowledge around prior authorizations, the National Board of Prior Authorization Specialists (NBPAS), a division of the Accreditation Council for Medical Affairs (ACMA), provide the Prior Authorization Certified Specialist (PACS) Program. PACS is currently the first and only accredited program that focuses on building expertise in ensuring patient access from PAs.

Topics range from coverage determination types, buy and bill, how to read medical records, addressing appeals and denials, and strategic methods to reviewing authorization applications. Data presented at the American Society of Health System Pharmacists Mid-Year Conference (2021) by the ACMA/NBPAS and Rutgers University Ernest Mario School of Pharmacy showed that learners enrolled in the PACS certification program showed statistically significant increases in knowledge improvement related to the prior authorization and reimbursement field