Prescription Medication Prior Authorization Explained
Summary
TLDRDr. Eric Bricker discusses the cumbersome process of prescription medication prior authorizations in healthcare. He outlines the steps, challenges, and implications of the system, including the time-consuming nature and potential for delays in care. The video highlights the impact on physicians, patients, and the healthcare system, emphasizing the need for improvement and the role of electronic prior authorizations in streamlining the process.
Takeaways
- 🔑 The video discusses the process of obtaining prior authorization for prescription medications, highlighting the complexity and challenges faced by healthcare providers.
- 👩⚕️ The term 'prescriber' includes various healthcare professionals such as doctors, nurse practitioners, physician assistants, and even podiatrists or dentists who prescribe medications.
- 📋 The number of medications requiring prior authorization can be extensive, with the example of CVS listing approximately 495 medications that necessitate this process.
- 🔍 Determining whether a medication requires prior authorization can be difficult and varies depending on the insurance carrier or pharmacy benefit manager (PBM).
- 📄 Traditional methods of obtaining prior authorization, such as using fax machines, are still prevalent but are being supplemented by electronic methods to streamline the process.
- 💻 Electronic prior authorizations involve intermediaries like CoverMyMeds and SureScripts, which act as a bridge between prescribers and PBMs.
- ⏱ The process of prior authorization can be time-consuming, with physicians reporting that it often takes one to three business days to receive approval or denial of requests.
- 🚫 The denial of prior authorization requests can occur for various reasons, including the prescriber's specialty, patient age, lab values, and BMI, which must align with the PBM's criteria.
- 🤔 The role of the pharmacist in the prior authorization process involves subjective clinical judgment, which can introduce variability in decision-making.
- 🏥 The impact of the prior authorization process on patient care is significant, with delays in treatment and potential adverse events, including hospitalizations.
- ⏲️ Physicians spend a considerable amount of time on prior authorizations, with an average of 14 hours per week, which detracts from time spent on direct patient care.
Q & A
What is the main topic of Dr. Eric Bricker's video?
-The main topic of Dr. Eric Bricker's video is prescription prior authorization, discussing the steps involved in obtaining it and the challenges faced in the process.
What is a prescriber in the context of pharmacy?
-A prescriber in the context of pharmacy refers to anyone who can prescribe medication, which can include doctors, nurse practitioners, physician assistants, podiatrists, and sometimes dentists.
Why is it difficult to determine if a medication requires prior authorization?
-Determining if a medication requires prior authorization is difficult because it depends on the insurance carrier or pharmacy benefit manager (PBM), and each may have a different list of medications requiring prior authorization.
How many medications on CVS's formulary require prior authorization according to Dr. Bricker's count?
-According to Dr. Bricker's count, about 495 medications on CVS's formulary require prior authorization.
What are some of the methods used for submitting a prior authorization request?
-Some methods for submitting a prior authorization request include using fax machines, standardized prescription prior authorization forms, and electronic prior authorization systems like CoverMyMeds, SureScripts, or direct electronic means from individual PBMs.
What is the role of a prior authorization technician (PA tech) in the process?
-A prior authorization technician (PA tech) is responsible for abstracting information from the prior authorization request, which may come in via fax, and entering it into the PBM's system.
What is the average caseload for a prior authorization pharmacist according to the video?
-According to the video, a prior authorization pharmacist is expected to handle 60 cases per day, which averages to reviewing one case every eight minutes.
What are some criteria used by prior authorization pharmacists to approve or deny a request?
-Some criteria used by prior authorization pharmacists include the patient's age, lab values such as blood glucose levels and BMI, and the prescribing physician's specialty.
What is the impact of the prior authorization process on patient care according to the survey mentioned in the video?
-According to the survey, the prior authorization process can delay care half the time, cause adverse events in patients 24% of the time, and result in hospitalizations 16% of the time.
How much time do physicians spend on prior authorizations per week on average, as per the survey?
-The survey indicates that physicians spend about 14 hours per week on prior authorizations, handling an average of 33 prior authorizations.
What is the effort being made to streamline the prior authorization process?
-The effort to streamline the prior authorization process includes the implementation of e-prior authorization systems, which aim to reduce the time and complexity involved in the traditional methods.
Outlines
🩺 Introduction to Prescription Prior Authorization
Dr. Eric Bricker introduces the topic of prescription prior authorizations, emphasizing its importance in healthcare. He explains that while he has discussed prior authorizations in general in a previous video, this video focuses specifically on those required for prescription medications. Bricker outlines the initial steps in the process, starting with the prescriber, and highlights the challenges in determining whether a medication requires prior authorization, which varies depending on the insurance carrier or PBM (Pharmacy Benefit Manager).
📠 Methods of Submitting Prior Authorizations
The video explains the different methods of submitting prior authorizations for medications. While many healthcare providers still rely on fax machines, some states like Illinois have standardized forms. However, electronic prior authorizations are becoming more common, though not universally adopted. Bricker discusses the intermediaries involved, such as companies like CoverMyMeds and SureScripts, which facilitate electronic submissions. The process can be complicated, with healthcare providers using a mix of electronic and manual methods.
💻 Processing Prior Authorizations within PBMs
Dr. Bricker delves into the internal process within PBMs after a prior authorization request is submitted. A prior authorization tech enters the request into the system, which is then reviewed by a pharmacist. Bricker shares insights from a prior authorization pharmacist who describes the challenges of reviewing 60 cases per day, highlighting the variability and complexity of these cases. The pharmacist’s subjective clinical judgment often plays a significant role in the approval or denial of requests.
⏳ Time Delays and Impact on Patient Care
This section discusses the time delays involved in the prior authorization process and its potential impact on patient care. Dr. Bricker notes that in Illinois, responses must be provided within 24 to 72 hours, but delays can still occur, potentially leading to adverse events or hospitalizations. He emphasizes the burden this process places on physicians, who spend significant time on prior authorizations, potentially detracting from patient care. Efforts to streamline the process through electronic systems are ongoing but not yet fully effective.
Mindmap
Keywords
💡Prior Authorization
💡Prescriber
💡Pharmacy Benefit Manager (PBM)
💡Formulary
💡Electronic Prior Authorization
💡Cover My Meds
💡Surescripts
💡Clinical Criteria
💡Adverse Events
💡E-Prior Authorization
💡Public Health Threat
Highlights
The video discusses the process of obtaining prior authorization for prescription medications.
Prescribers, including doctors, nurse practitioners, and other medical professionals, may need to obtain prior authorizations for certain medications.
The number of medications requiring prior authorization varies by insurance carrier, with CVS listing around 495 such medications.
The process of determining if a medication requires prior authorization can be challenging and differs by pharmacy benefit manager (PBM).
Fax machines are still commonly used in healthcare for prior authorization requests, despite efforts to move towards electronic methods.
Electronic prior authorizations involve intermediaries like CoverMyMeds and SureScripts, which help streamline the process.
Physicians often use a combination of fax machines and electronic methods for prior authorizations due to the lack of a standardized approach.
The prior authorization department within a PBM involves multiple steps, including data entry and review by pharmacists.
Prior authorization pharmacists may have to review up to 60 cases per day, which can be a demanding workload.
Criteria for prior authorization can include age, lab values, BMI, and physician specialty, which can lead to denials.
Subjectivity in clinical judgment by pharmacists can result in variability in the approval or denial of prior authorization requests.
Delays in prior authorization can lead to delays in care, with half of physicians surveyed reporting such delays.
The prior authorization process has been associated with adverse events and hospitalizations due to its complexity and time demands.
Physicians spend an average of 14 hours per week on prior authorizations, time that could be used for other patient care activities.
Efforts to improve the prior authorization process through e-prior authorization are ongoing but not yet fully effective.
The video emphasizes the impact of the prior authorization process on patient care and the healthcare system as a whole.
Transcripts
hello this is dr eric bricker and thank
you for watching a health care z today's
topic is prescription
prior authorization now i've made a
previous video about prior
authorizations that i will leave a link
to in the show notes but this one
specifically talks about prior
authorizations for prescription
medications because what's one of the
most common things that we get at the
doctor's office is a prescription for a
medication and a lot of times it
requires prosthetic prior authorization
so we're going to go through the steps
that it takes to actually obtain a prior
authorization for a medication so
obviously it starts off with the
prescriber now i specifically use the
word prescriber here because in the
world of pharmacy that's what they call
people who prescribe things prescribers
it could be a doctor it could be a nurse
practitioner it could be a physician's
assistant shoot it could even be a
podiatrist or a dentist sometimes they
prescribe antibiotics etc so they call
them prescribers they all kind of lump
them together okay so then obviously
there's medications that require author
prior authorizations and they're
medications that don't require prior
authorizations how do you know well that
first step is actually pretty difficult
and it depends upon who the insurance
carrier slash pbm is and i'll leave a
link in the show notes to describe what
a pbm is we are not going to go over
that in detail that is a whole other
topic in and of itself okay so
you can just go online and you can look
up cvs's formulary and you can actually
see they list the medications that
require prior authorizations guess how
many medications it is it's about 495
medications now i started counting them
and it was so many i'm like i'm just
going to count how many are on a page
and there was about 45 per page and then
i counted okay well how many pages are
there there's 11 pages of prior
authorization medications so for cvs
there's about
495 medications that require
prioritization but that could be
different for express scripts ever north
that could be different for prime
therapeutics that could be different for
optum rx so just the first step of
figuring out if the medication does or
does not require prioritization it's a
little challenging if you wanted to be
proactive i mean you could just order
the you know write a prescription for
the medication and just get the denial
from the pharmacy you could just find
out that way but if you wanted to be
proactive it's actually kind of
difficult to do that okay next there's a
couple of ways to do it shoot of course
in healthcare we use fax machines and so
they're in certain states i looked up in
the state of illinois they actually have
a standardized
prescription prior authorization form
that has to be used across the entire
state of illinois but the problem is is
that it has 40 fields that you have to
fill out
for this facts
or you can do it the way that this gets
us to the 21st century we're trying to
move towards
electronic prior authorizations but
believe me
there are many
doctors
hospitals ambulatory surgery centers you
name it that still use the fax machine i
know for a fact my kids pediatrician's
office still uses the fax machine and
they've got like six pediatricians
there's not some like you know small
hocus pocus pediatric practice i mean
it's like a huge practice okay now if
you do it electronically interestingly
there's actually another vendor in
between the prescriber and
the
pbm
that is
the electronic go-between now who are
those companies one was called cover my
meds which is a subsidiary of mckesson
another one is called surescripts that
i've also talked about in a previous
video i'll leave a link to it in the
show notes which is actually co-founded
and co-owned by
cvs and express scripts and then each
individual pbm also has their own
um
sort of direct electronic
uh means of submitting a um
prior authorization as well so there's
sort of a handful of ways you could do
it so it brings up this sort of like
permutations and combinations where it's
like okay for some you might do fax
machine but for other you might go
through cover my meds and for other
folks that don't use cover my meds or
short scripts they might have to go to
the individual ones
uh electronic sites for some but then
fax others and in fact i'll leave a link
to a fantastic uh summary of the sort of
the state of electronic prescribing in
america in the show notes and it
actually says that the majority of
physicians use a combination of these
routes for doing their medication prior
authorizations so it's not just one
route it's not like people just do the
fax machine or they just do
e-prescribing that most physicians
actually use some sort of combination
when they're doing prior authorizations
okay so then it goes over to
the um
prior authorization sort of department
within the pbm and the prior
authorization tech especially if it
comes in via fax has to abstract the
information from that fax and actually
hand type it into the system within the
pbm now you can imagine there could be
some recording errors if you're taking
it off of a fax and putting it into a
system whether it be maybe putting too
many zeros or too few or what have you
or misspelling something okay so the pa
tech enters into the system and then it
goes over through that system to a
prior authorization pharmacist at the
pbm now
there's a fantastic video by a prior
authorization pharmacist on youtube that
i got this information from and she kind
of describes her work day now this is
just her experience but it kind of pulls
back the curtain a little bit to give
you more information about what she does
as a prior authorization pharmacist so
she says that she is expected to do
60 cases per day which for an eight-hour
day which means that they she would need
to review eight a case every eight
minutes now a case could be like one
person and that person could just have
one prescription or it could be multiple
prescriptions so there's probably
varying degrees of complexity there she
specifically is new to being a prior
authorization pharmacist and she says
that she has a really hard time doing 60
a day she says that if she's like going
like really fast she can do like 50 but
she has a really hard time doing 60.
that's just her experience maybe there's
other prior authorization pharmacists
who can easily do one review every eight
minutes i don't know i'm just sharing
what she shared okay now then they
review the information and put it by the
prior authorization criteria and some of
the criteria are based on things like
age so there's certain medications that
just will not be authorized if you're
either let's say below 18 or over 18.
example of that is um is retinol
for a retinoic acid for acne so a lot of
times a plan will require prior
authorization for
retinol for treating acne and they'll do
it for people under the age of 18 but
they won't cover it if you're over 18.
so that's why they need the age
sometimes it's on lab values so believe
it or not there's and i'm just giving
you certain examples there's many other
examples there's actually certain um
psychiatric medications so uh
risperidone or risperdal that actually
can have problems with having high blood
glucose levels it can cause you to gain
a lot of weight and it can even
predispose you to potentially getting
diabetes and having a high blood sugar
so there they actually need lab values
they need to know what your the
patient's blood glucose level is and
make sure that it's not too high in
order to approve the risperdal likewise
they need to make sure that you that
you're not
overly obese so they need your bmi as
well and even if the lab values and the
bmi are fine again you don't necessarily
know up front
what information like there's no place
on that fax to put in bmi and glucose
levels like you don't know it's a
standard form for all medications so
there are
certain requirements that even if like
the patient like fits it if it wasn't
submitted with the prior authorization
it's gonna get denied okay we need to
know what their glucose is this is less
than 120 well shoot it might be less
than 120 but if they haven't submitted
it then they're going to deny it okay
next up interestingly she says that
certain medications are
denied because the prior authorization
requires that the physician be of a
specific specialty
specifically like for the retinol for
the retinoic acid you got to be a
dermatologist oh that was interesting
that's the first time i ever had heard
that a denial would actually be done
just solely based upon the specialty of
the physician the clinical criteria for
the patient might be totally fine bmi is
fine um glucose is fine you don't need
that for retinol but you get my point
but just the fact that the doctor was or
was not a certain specialty denial and i
thought myself well that's kind of hard
especially if you're like in a rural
area or like an inner city like you
might not have access to a dermatologist
and i think
this is my clinical opinion i think it's
perfectly reasonable for like a
pediatrician or for a family practice
doc
to prescribe
retinol i mean it's a cream and you got
to be careful with it that you don't put
too much on
and you can um
you know potentially have adverse side
effects with your skin with it like with
many creams but to say that only a
dermatologist can prescribe retinol um
just seemed a little odd to me okay now
the interesting thing too she said
many times it requires her independent
clinical judgment as a pharmacist
as to decide whether or not to approve
or deny a prior authorization request
and i thought that was very interesting
because she herself was saying like a
lot of it was very subjective and just
to based upon her own clinical uh
opinion now obviously in between doctors
you got different clinical opinions so i
would imagine in between pharmacists you
have different clinical opinions as well
so there's some degree of subjectivity
now
let's say you get through all that great
it's approved you've got to put the
pharmacy on here so they approve it for
that pharmacy great but if they deny it
they send that back to the doctor's
office with the denial now interestingly
in the state of illinois it has to be
done
within 72 hours or you can check a box
that says look this is clinically urgent
in which case it needs to be done within
24 hours but if you're prescribing
something let's say in the morning like
the patient is not necessarily going to
be able to pick it up the same day or
that afternoon like they might have to
wait overnight even if it's quote
unquote urgent and i can tell you like
there are absolutely situations where
like let's say i'm prescribing a blood
pressure medication i'm like dude i see
you in the office you come in for a
blood pressure check your blood pressure
is elevated but i want to get you on
something like now and i could probably
keep you out of the er and i could
probably keep you out of the urgent care
center or what have you if i can kind of
get you
on that you know you know we used to use
my phetipine xl a lot
30 milligrams for people that had you
know pretty pretty high blood pressure
but then lyfine actually works pretty
well pretty fast so you could get them
the knife therapy maybe have them come
in the next day for a blood pressure
check make sure they were doing okay and
you could keep them out of the hospital
or keep them out of the er for doing
that okay so
now they do put their rationale for the
denial on there oftentimes she says they
do use templates now it goes back to the
doc as you can imagine the doc can then
should just change the medication and
either do a medication that doesn't
require prior authorization at all or go
through a medication that requires a
different type of prior authorization so
you go through this whole process again
or they could add additional clinical
information they could be like oh well
i've got their blood sugar and i've got
their bmi for the risk for all so we can
just put that on there and get it and
then okay additional clinical
information is on there great i didn't
know you needed it now i gave it to you
now they can approve it or you know
let's say the person's you know bmi was
too high or the glucose was you know
let's say it was 121 it had to be less
than 120 or whatever the amount was and
then they would deny it again
and at that point the physician's office
can be like well look you know i don't
agree with your clinical assessment for
why i can't prescribe this medication at
which point it's escalated to the
medical director and then the medical
director would interact with the
doctor's office and the medical director
could trump it and they could just
approve it or it would just be a denial
and be like look the medical instructor
was like look this is the way it is
we're not going to change our decision
around the authorization denial okay so
as you can imagine when you've got the
proscriber
you've got an intermediary for
submitting the information you've got
the actual
pbm that has multiple parties within it
you've got the tech you've got the
pharmacist and then you potentially have
the medical director that just from a
process like the point of this video
is not to go into the detail around like
the clinical appropriateness of whether
you should do this or should not do this
i mean believe me that is a legitimate
conversation but it's just not the point
of this article today the point is is
that it takes time it slows things down
it's cumbersome it's prone to error what
are the implications of that what are
some of the results of that so
again from a fantastic article i'll
leave a link to in the show notes a
survey a physician said that 64 of the
surveyed physician says say that they
have to wait
one business day to hear back anything
regarding a prior authorization denial
or or uh approval
29 so we're going on almost a third of
doctors say that they have to wait um
three business days for the
approval or the denial so that kind of
fits within the 24 to 72 hours for the
state of illinois that kind of goes
along with the general understanding
here as well now interestingly the
surveyed physicians also said that
half the time for like half those prior
authorization requests that they made
that this one business day or three
business day caused a delay in care okay
so you could wait a business day and
you're like oh
you know it's kind of annoying but it
doesn't really you know delay care per
se because you know let's say they
already had enough pills at home they
hadn't run out yet you were getting a
prior authorization on a refill or a new
prescription etc so like it didn't delay
care because they still had some pills
left at home okay
this is the opposite of that this is
saying half the time it actually delays
care it delays the treatment of the
behavior disorder or the depression
it delays the treatment of the acne it
could delay much more you know serious
conditions as well now
24 percent of the surveying physicians
say
that
the prior authorization process and just
the time that it takes
causes and have caused adverse events in
their patients
and 16 percent say that they've actually
resulted in hospitalization so that just
the process so one of the things that we
talk about on a healthcare system is how
the healthcare system itself is actually
a public health threat so the point is
let's say you had you know something in
the water or let's say you had a bug
that was transmitting a germ right they
would those you know those things in the
water or those germs that are
transmitted by butt they might have like
a 24
rate of adverse events in patients or
that you know that particular germ in
the bug might cause 16 hospitalizations
the point is the health care delivery
system and payment mechanism
itself is a public health threat akin to
dirty water and germs from insects okay
so the argument against that is that
well this is just payment the doctor
needs to do the right thing independent
of family listen i'm just saying that
regardless of
whether or not
you think this process actually should
impact clinical care the point is with
these surveyed physicians it does again
that's up for discussion but that's
essentially what these doctors who are
surveyed are saying and many would agree
with them okay so
at this time it takes a lot of time fine
what does it take in terms of the
prescriber's time they say that they do
the survey physicians say they do
33
prior authorizations per week and that
it takes them
about 14 hours of their week to do it
now keep in mind
that there's an opportunity cost so that
is
14 hours that they are not spending
thinking about
other things with their patients so
there has been an effort to do
e-proscribing
to improve this process
and
just going into the details excuse me
not e-prescribing the e-prior
authorization now e prior authorizations
they have their pros they have their
cons it is the effort that is being made
now to try to streamline this process
we're not there a hundred percent so
just know that in the meantime
for you as an individual patient for you
as an hr leader for you as a broker
benefits consultant just know that your
health plan members right now are being
subjected to a process
that
24
of the time can result in adverse events
and 16 of the time has resulted in
hospitalizations
so that's my point for today thank you
for watching a healthcare z
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