UNDERSTANDING THE PRIOR AUTHORIZATION APPEALS PROCESS
Even if a prior authorization is denied, there is still recourse for providers and patients who feel that a drug is the appropriate option for the individuals’ specific health needs. This appeals process starts with review by an internal medical director at the PBM, who looks at all evidence presented, as well as FDA indications and documentation from the prescriber. This data is used to make a determination whether or not the appeal should be granted. A second-level appeal may also be pursued if this initial process results in a denial. In this case, an arbitrator outside of the PBM and payer will look at the same information mentioned above and approve or deny the appeal.
Forms and documentation related to these processes can typically be found on a health plan’s website. However, in the case of specialty drugs, pharmacies like Avella will also take an active role in this process, reducing the burden on providers and patients alike.
TOP TRENDS IN PRIOR AUTHORIZATIONS
As the prior authorization process is changing, it’s important to understand how these changes will impact requirements for additional diagnostic efforts and documentation. From a PBM’s perspective, we’re seeing much more emphasis on genetic testing and genotyping for cancer, cystic fibrosis and hepatitis C virus (HCV). Genetic testing for many different disease states across the board is becoming more common, but it is definitely most prevalent in oncology.
Payers are also relying more heavily on step therapy. Step therapy is a progressive approach that involves trying a more commonly prescribed therapy first to see if the patient receives clinical benefits before moving on to newer, more expensive and possibly more unproven drugs. Step therapy is already used by many health plans today, but it’s becoming increasingly common as drug costs rise.
Another important trend is an increasing emphasis on greater evidence-based medicine—which aligns with the greater movement toward data-driven decision-making in the healthcare industry. PBMs are looking at fact-based results to determine drug efficacy and appropriateness. Committees may evaluate all options, look at clinical evidence and then develop processes based on this research. Some of the questions we ask ourselves in this process include:
For example, evidence may show that a cancer patient taking a certain therapy shows a five-month longer progressionfree survival rate. This is good news—but is it actually prolonging life and improving the patient’s quality of life? In another example, drugs for patients with cystic fibrosis consider clinical evidence with regard to forced expiratory volume (FEV)—the amount of air exhaled during a standard test. Certain drugs for the condition may cost upwards of $100,000. Careful consideration of how much a therapy impacts FEV as well as the patient’s quality of life would be important in assessing the value of these drugs. In many cases, high-cost drugs may improve FEV 10%. In this case, the evidence-based process would involve determining whether that result is clinically significant, whether it is enough of an improvement, and whether it is helping the patient’s overall quality of life.
REMOVING ROADBLOCKS IS KEY TO MANAGING THESE REQUIREMENTS
Given that these trends will make prior authorization requirements more complex in years to come, it’s important to examine the ways in which providers, patients and pharmacies can work together to make this process easier. For providers, understanding the basics of prior authorization requirements is a given. However, the nuances of the process may be different for specific payers. This may also be more difficult for physicians who don’t commonly treat specific disease states—as prior authorization requirements can be vastly different for rheumatoid arthritis versus hepatitis C, for example. In the case of hepatitis C, requirements may include distinct questions about active drug use and ongoing sobriety, to ensure that patients are more likely to be adherent with the medication.
That’s where partnering with a specialty pharmacy like Avella can help. Avella’s staff of clinical experts processes more than 10,000 prior authorizations per year. As a result, these experts have advanced knowledge of the type of documentation needed to expedite a decision and help assure approvals when a drug is clinically appropriate. At the same time, specialty pharmacies can also provide other valuable strategies—like patient education, medication adherence tools and other important services—helping ensure that once a patient receives approval for a specific drug, they receive the full benefit by taking it correctly.
For other drugs that aren’t distributed through a specialty pharmacy, physicians may find it easier to submit prior authorizations through the payer’s website, allowing them to avoid the back-and-forth involved in phone inquiries. Large physician practices may also want to designate one or two team members to handle prior authorizations for the entire practice.
Electronic prior authorizations are also becoming more commonplace. New standards have streamlined this process within e-prescribing. In this model, real-time information from a provider’s electronic health record (EHR) is exchanged between the prescriber and the patient’s health plan. When EHRs leverage this new capability, physicians can reduce the time spent filling out paper forms, faxing and navigating payer portals. These systems can notify providers in advance of prior authorization requirements before e-prescribing, and pre-populate required patient information, reducing manual entry and paperwork. This process may also speed the time it takes for prior authorizations to be submitted and reviewed, which is especially important when patients with life-threatening illnesses like cancer are waiting for important therapies. While this technology is still in its infancy, electronic prior authorization is expected to become a standard in the industry as these systems evolve over time.
THE PATIENT’S ROLE AS AN ENGAGED, INFORMED HEALTHCARE CONSUMER
Patients can also play a role in streamlining this process, even though they are not directly involved in submitting documentation. One important point for patients to remember is that prior authorization itself shouldn’t be a roadblock for appropriate care. If a patient hears from their pharmacy that a medication “is denied” by the insurance company, it’s important for this individual to question why and if there is anything they can do about it. In some cases, a retail pharmacist may not explain the prior authorization need to the patient correctly—ignoring the need to provide proper assistance, patient advocacy and support. In this case, the patient should contact their physician directly, and seek the help of a pharmacy willing to work on their behalf. This approach is supported by numerous studies showing that engaged, informed patients who are accountable for their own care are more likely to have a positive healthcare experience.
Patients must also be transparent about issues related to their condition, treatment and drug efficacy. This is especially important as providers and payers seek to determine whether a therapy will improve a patient’s quality of life. In addition, prior authorization requirements may include sensitive subjects about an individual’s mental health or substance abuse issues, like those mentioned for hepatitis C. It’s important that patients understand why these issues may impact their ability to fully benefit from a specific therapy—and that they must address these concerns to receive approval.
COLLABORATION IS KEY TO SUCCESSFUL OUTCOMES
In summary, while prior authorizations can be perceived as a hassle for physicians and patients, they are becoming an increasingly important mechanism for dealing with skyrocketing healthcare costs. Rather than focusing on the negative, it’s only through active collaboration—between payers, PBMs, providers and patients—that we can ensure this process is a positive one for the patient. Because when we all focus on patient safety, along with responsible spending and appropriate evidence-based care, everyone in the healthcare system ultimately benefits.
The original version of this article was published in the summer 2015 issue of Dispensing Excellence. Download the latest issue to access the full digital copy of the publication and more information on prior authorizations as a critical part of the cost-control strategy.
This article was written by Steven G. Avey, RPh, MS, FAMCP, Vice President, Specialty Programs at MedImpact Healthcare Systems, Inc. Steven Avey is a distinguished expert in managed care pharmacy, quality measurement programs and the improvement of drug assessment processes. He serves as vice president of specialty programs at MedImpact. Previously, Steven worked for Prospective Health (now Relay Health) establishing its data services division, served as president of managed care at Partners Rx Management, and held a leadership role at RegenceRx. He was also the president and treasurer of the Academy of Managed Care Pharmacy (AMCP) before becoming the executive director of its foundation and is the namesake of its prestigious Steven G. Avey Award. Steven holds a bachelor’s degree and Master of Science degree in pharmacy administration from the University of Utah.