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.

Outlines

00:00

🩺 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).

05:01

📠 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.

10:01

💻 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.

15:03

⏳ 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.

Keywords

💡Prior Authorization

Prior Authorization is a process required by some insurance providers before they will cover the cost of a prescribed medication. It is central to the video's theme as it outlines the steps and challenges involved in obtaining approval for medication prescriptions. The script discusses how this process can be cumbersome and time-consuming, affecting patient care and potentially leading to adverse events.

💡Prescriber

A 'Prescriber' in the context of the video refers to any healthcare professional authorized to prescribe medication, which includes doctors, nurse practitioners, physician assistants, and even podiatrists or dentists in some cases. The script emphasizes the role of prescribers in initiating the prior authorization process for medications.

💡Pharmacy Benefit Manager (PBM)

A Pharmacy Benefit Manager, or PBM, is a third-party administrator of prescription drug programs for insurance companies and employers. In the video, PBMs are responsible for handling prior authorization requests, determining whether a medication will be covered based on various criteria.

💡Formulary

A formulary is a list of medications that an insurance provider will cover. The script mentions that different insurance carriers have different formularies, which can make it challenging to determine whether a medication requires prior authorization.

💡Electronic Prior Authorization

This refers to the modern method of submitting prior authorization requests electronically, rather than through traditional methods like fax. The video discusses the transition towards electronic prior authorizations as a way to streamline the process, although it also acknowledges the persistence of older methods like fax machines.

💡Cover My Meds

Cover My Meds is a vendor that acts as an intermediary for electronic prior authorizations between prescribers and PBMs. It is mentioned in the script as one of the companies facilitating the transition to a more modern, electronic process for handling prior authorizations.

💡Surescripts

Surescripts is another intermediary company that facilitates electronic prior authorizations. The script highlights its role as a co-founded and co-owned entity by CVS and Express Scripts, indicating its significance in the pharmacy industry.

💡Clinical Criteria

Clinical criteria are the medical guidelines or standards used by PBMs to determine whether a medication should be covered. The video explains how certain criteria, such as age or lab values, are used to approve or deny prior authorization requests.

💡Adverse Events

Adverse events refer to any negative health outcomes that occur due to medical treatment or processes. The script cites a survey indicating that the prior authorization process can sometimes lead to adverse events or even hospitalizations for patients.

💡E-Prior Authorization

E-Prior Authorization is an effort to improve the prior authorization process by making it electronic, which is intended to reduce the time and effort required by prescribers. The script discusses this as an ongoing initiative to streamline the process and improve patient care.

💡Public Health Threat

The term 'public health threat' is used in the video to describe the potential dangers posed by the healthcare system itself, particularly the prior authorization process, which can delay treatment and lead to adverse outcomes for patients.

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