Prescription Medication Prior Authorization Explained

Summary

Dr. 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.