The insurance industry created prior authorization to provide appropriate and cost-effective healthcare services and medications for patients. Pharmacies have continued to see an annual rise in the number of prior authorizations in their workflow and will likely see this trend continue as specialty medications increase. Additionally, the American Medical Association estimates that prior authorization costs U.S. physicians billions of dollars each year, and the costs incurred by insurers are significantly higher. This creates potentially increased risk for patients because every claim delayed or denied creates a new liability for health insurers.

Prior authorization generally improves the use of evidence-based treatments and reduces prescription costs; however, the barriers created by the approval waiting process result in many prescriptions going unfilled, leading to possible abandonment of therapy and ultimately increasing the likelihood of noncompliance. This has a negative impact on patient health outcomes.

So what can pharmacies do to increase the chance that a prior-authorization request will go through the system expeditiously to support positive patient outcomes?

Pharmacists need to get more involved, further expanding their role as caregivers and taking the lead as all-encompassing patient-care coordinators. Additionally, available technologies, such as electronic prior-authorization services, give pharmacies the ability to engage early in the prior-authorization process, minimizing wait time and maximizing patient-care support.  

These technologies are sometimes limited by stakeholders, including the vendor, the payer, the pharmacy, and provider prescribing preferences.  Electronic prior-authorization services are HIPAA-compliant and can integrate with legacy pharmacy systems. Such technologies offer simple methods for providers to submit forms electronically, while others support the entire ecosystem for prior authorization.

Many technologies now streamline the process, autopopulating patient information from various record sources. An example is CoverMyMeds, which touts an average time spend of 1 to 3 minutes to complete the process electronically. Electronic prior-authorization services also allow payers to approve the therapy in real time and help patients access their medication during their first visit to the pharmacy.

Payers can help improve the efficiency of the prescription-drug prior-authorization process by reducing unnecessary regulations and implementing various electronic prior-authorization protocols with step therapy overrides in the event that beneficiaries experience adverse effects. One company on the forefront is Medscient, which offers a system that provides a distinct, ultrascalable solution to maximize stakeholder savings. Every referral is autoapproved, which means one less potential liability for the provider/payer.

Positive-step payers are actively working to avoid policy changes that impede a beneficiary’s medication treatment. Also, eliminating redundant approval processes for patients participating in step-therapy programs should prevent their having to retry failed therapies based on benefit restrictions. As well, payers are working toward shortening therapy review times.

In addition, payers are communicating more with providers about expediting appeals for prior-authorization treatments depending on a patient’s healthcare status, such as during emergency situations. Pharmacies that are actively engaged with the provider have the best chance of avoiding the excessive delays associated with prior-authorization protocols, maximizing efforts to balance the business of pharmacy while optimizing patient care.

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