Tips and Tricks
Our experts put their heads together to create this list of prior authorization tips for allergy practices and staff.
- Institute policies and procedures to stay organized and make obtaining a prior authorization (PA) easier.
- Use a standing order for a substitution list for commonly prescribed medications. If a medication is not on formulary, this approach allows staff members to substitute one of the medications on the list instead of going through the prior authorization process. The list includes antihistamines, nasal steroids, nasal antihistamines, eye drops and albuterol metered-dose inhalers.
- Use a PA binder or a folder on your computer to keep prior authorization forms and information required by insurance companies in one place. The binder should contain a list of insurance contact numbers, insurance requirements, CPT codes, DX codes and hospital NPI numbers, particularly if infusions are ordered. By keeping the folder on your servers, every staff member should be able to access this information, no matter where they are.
- Pick the appropriate person to oversee PAs. The skill set that makes a person a great receptionist (agreeable and accommodating) might not be the best for managing prior authorizations. Pick someone who is detail-oriented and who is a bulldog who refuses to take “no” for an answer.
- Train staff members and review high-dollar prior authorizations before submission. Sometimes biologics are rejected because the wrong section was checked on a confusing form. Make sure your staff is trained properly on how to submit prior authorizations, and consider reviewing high-dollar PAs prior to submission.
- Use technology to your advantage.
- Include a tab in your EHR to document “Medications Tried in the Past.” Nurses should ask patients whether they have tried any allergy or asthma medications and whether the patients had success or failure with those medications. PA staff members can use this documentation, if necessary.
- Keep prior authorization documents and responses together in your patient’s EHR file. Scan the patient’s PA documents and communications under a separate category, “Prior Authorizations,” to make them quickly accessible and to use as reference for future PAs.
- Have front office staff members collect and scan pharmacy benefit manager (PBM) insurance cards - as well as commercial insurance cards, if patients have both. The PBM number is now accessible for electronic prior authorizations submitted through the EHR.
- Submit PA requests electronically. Avoid spending hours on the phone with insurers or filling out prior authorization forms by hand and then wasting time waiting for faxed paperwork to go through. Use one of these websites to submit prior authorizations electronically or check other online submission options for your insurers. (Note: Using these services may trigger an increase in electronic requests for PAs.)
- Surescripts (https://providerportal.surescripts.net/providerportal)
- Covermymeds (www.covermymeds.com/main)
- Engage patients in the PA process.
- Make sure patient information is up to date. When obtaining a renewal for biologics, contact the patient first to determine whether any insurance information has changed.
- Confirm that your patient wants the medication, even if it has the highest copay. Many medications that require prior authorizations also have the highest copay. Some patients may prefer to switch to lower-cost medications if the physician thinks it will be just as effective.
- Ask your patients to call their insurance company. Patients can call their insurance carrier to investigate which medications are on formulary through their plan if the medication recommended for their treatment plan isn’t covered. This approach eliminates the need for prior authorization paperwork.
- Coach patients or parents of patients to contact their benefits managers. Many large, private employers that provide benefits for their workforce have a benefits manager. This usually is the person who writes the premium check each month to the insurance carrier that administers the plan. If a benefits manager calls an insurance carrier to request coverage for a drug under the employer’s plan, the insurer usually listens.
The benefits manager of a large law firm called the firm’s insurance carrier on behalf of a dependent child whose prior authorization for sublingual tablets had been rejected, and the insurer agreed to pay for the medication.
- Add patient resources to your website. Patient resources, such as medication coupons and internet sites for cost savings on prescriptions, should be included on your practice website. Consider adding the following links:
- Internet Drug Coupons: This website features the largest database of manufacturer drug coupons available to the public. Patients can find discounts or rebates on the drugs prescribed for them. Patients can view coupons by ailment categories or search for specific coupons.
- GoodRx app: This free, easy app helps patients compare medication prices at local pharmacies to find the best deal. Patients can also search for coupons, which can be used straight from the app.
- Do some problem-solving before you respond to a a prior authorization request or a rejection notice that you believe is incorrect.
- Has the patient requested a refill too soon? Most insurers allow early refills, but usually not before day 23. Instead of telling you the refill is too early, sometimes the pharmacy simply requests a PA.
- Has the drug store entered the wrong National Drug Code (NDC)? Errors happen. Ask the pharmacy to confirm that the number is correct.
- Does this pharmacy routinely have this problem? Sometimes pharmacy computers are not programmed correctly, and a store may request a prior authorization for medications that don’t require one. While this is worth a call to the pharmacy, don’t waste time with locations that routinely have this problem. It could be an exercise in futility. Often the best advice to give your patient is to find a new pharmacy.
- Did the pharmacy contact the right insurer? Ask the pharmacy to send you the drug rejection notification it received from the insurance carrier. Sometimes after you submit a prior authorization, you get a response from the insurance company that they don’t cover the patient for this benefit. When this happens, confirm that the initial request went to the correct place. Compare the insurance plan listed by the pharmacy to the one you have for the patient.
- If the coverage matches the insurer you have on file, then the phone number in the rejection notice is usually the best place to start when determining how to file an appeal.
- If they don’t match, one or both of you has the wrong information. Contact the patient to confirm his or her current drug benefit plan - not the insurance plan, because they are often different. If the pharmacy has the wrong information, ask the patient to correct it.
Learn when to pick your battles. Why waste time doing a prior authorization for a specific brand of albuterol when you know they are all the same? Or for a drug on the "free list" at Publix or "$4 list" at WalMart? Ask yourself, ‘Is this prior authorization really worth the time and money my staff will spend on it?’
— J. Allen Meadows, MD, FACAAI
Patients should share with the insurance company why the treatment is important to them and how it will make a difference in their lives. It is every patient’s responsibility to take an active role and support the clinic’s efforts to obtain approval for coverage.
— Tonya Winders, president and CEO at Allergy & Asthma Network
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