Note: This is the first of a series of blog posts from the SOPIT Section Advisory Group for Ambulatory Care Informatics' Workgroup on Specialty Pharmacy.
“When we get mad, when we get angry, we get better.”
This is a quote from Coach Joel Quenneville of the Chicago Blackhawks. I must admit that when I first saw this quote, the first thing that sprang to mind was prior authorizations (PAs) and the need to ensure patient access to medications! There may be a lot of debate regarding the need for prior authorizations; I am personally glad when there is a triple check on a chosen hepatitis C therapy. However, completing my third zolpidem PA of the day becomes cumbersome (especially when I want to get home in time for the first puck drop). While PA forms may seem mundane and merely “red tape”, I hope to provide a different perspective on PA workflow. This, in turn, will hopefully streamline your processes and allow you to decrease time spent on PAs and appeals and increase productivity elsewhere.
Is the PA needed?
Think of this question as similar to looking at a urine culture (e.g. Do I need to treat?). Do I need to fill out this PA? Sometimes we are sent PAs because the patient is refilling too soon or the pharmacy has sent the PA to the wrong provider, etc. It is always a good practice to ensure that the PA is needed or that you are the correct clinician to fill out the PA prior to starting.
Clinical, clinical, clinical.
Why is the PA needed? Scrutinize each check box and question as each is usually related to insurance coverage criteria. There are times I can be reasonably sure that if I answer one question a particular way, the medication will likely be denied. I am not suggesting that anyone provide false information, however, this may cause me to do a little extra digging or double checking. I may also go to extra lengths to provide extra information. For example, if criteria for approval of a medication is “an increased cardiovascular risk”, clinical documentation in the form of a cardiovascular risk score may be helpful. I felt as though I had recorded a hat trick when I found a cardiovascular score specific to patients living with HIV that calculates risk based upon prior exposure to antiretovirals! Print out drug interaction reports or Child-Pugh score calculations! This extra bit of work up front to provide evidence may save hours of work if the PA is denied and a medical necessity appeal is needed.
There is no I in team!
Think big picture here. At my practice site, we have pharmacy students to help with PA and use online systems when possible to expedite submissions. Pharmacy students learn how to properly assess a PA for clinical evidence. Everything is double checked prior to submission and by utilizing pharmacist extenders, we are able to reach many more patients. Because you will be delegating, one of the most important game strategies will be ensuring an appropriate follow-up process! If you did not document it, it did not happen and if the insurance company did not receive your fax, no processing is going to happen either!
Regardless of your views on the need for the PA process, it is very satisfying to receive the “approval” fax and know that you have helped your patient gain access to their medication. So at the end of the day, clinical knowledge has been channeled into something “better” for your patient. I think that Coach Q could get behind that line.