In this edition of Dry Eye Fireside Chat, Damon Dierker, OD, FAAO, sits down with Christopher Wolfe, OD, FAAO, Dipl. ABO, to discuss how to manage prior authorizations (PAs) and optimize the process when treating patients with dry eye disease (DED).
What is prior authorization?
According to the American Medical Association (AMA), prior authorization is “a health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage.”1
PAs can be understood through two lenses, explained Dr. Wolfe; one is that doctors must outline the medical necessity of a prescription treatment or service to ensure it is medically appropriate for the patient.
Conversely, the “cynical perspective” is that PAs exist to deter doctors—and in his opinion, likely a high number of optometrists—who lack efficient systems to process PAs from prescribing branded medications in order to reduce costs for insurers.
The burden of prior authorization on clinicians
The American Academy of Ophthalmology (AAO) echoed these sentiments, describing PA as “a burdensome process” that often “delays necessary care while adding administrative burdens to physician practices.”2
In fact, a 2022 physician survey on prior authorization conducted by the AMA found that 88% of physicians who care for patients in the workforce reported the burden associated with PA as high or extremely high.3 Additionally, 34% of physicians reported that PA led to a serious adverse event, such as hospitalization, disability, or even death for a patient in their care.
Further, 94% of physicians reported care delays while waiting for health insurers to authorize necessary care, and 82% said that patients abandoned treatment due to authorization challenges with health insurers. Finally, the survey demonstrated that 35% of physicians have staff who exclusively work on PAs, and physicians and staff spend an average of 14 hours each week completing PAs.
Streamlining the prior authorization process
Dr. Wolfe highlighted that he encounters prior authorizations multiple times daily, particularly when prescribing medications for ocular surface disease—requiring him to implement a dependable and efficient system for processing PAs.
He added that it is critical for eyecare practitioners (ECPs) to have a PA protocol in place that “removes the doctor” from the equation. This means that the doctor doesn’t have to take time away from patient care to process PAs because the technicians and staff are trained and knowledgeable in completing them.
This helps to streamline the overall workflow, reduce frustration for both the practice and patients and, in Dr. Wolfe’s opinion, increase the number of medications doctors can prescribe because the overall process is more effective.
Optimizing patient charts to minimize PA denials
Dr. Wolfe outlined his practice’s system for processing PAs for dry eye patients. He emphasized that if a patient would benefit from being prescribed a specific branded medication that likely requires PA, he ensures that objective data is collected and the findings are recorded in the patient’s chart.
This includes reporting observations from the slit lamp examination, corneal or conjunctival staining, tear breakup time (TBUT), and lab tests like osmolarity and matrix metalloproteinase-9 (MMP-9) that are consistent with the disease state. Having this objective data in the chart is a preemptive step in obtaining PA approval by providing concrete evidence to justify prescribing the medication.
Further, he (or the scribe accompanying him) makes a note in the chart stating, “The clinical decisions I have made are based on clinical presentation, symptoms, and objective findings, including…”
This clear statement is helpful not only with obtaining PA approvals but also with billing and coding generally because it outlines why he performed a specific test and what he gained from the findings.
Consequently, when submitting a prior authorization, if the insurance company asks to review the chart notes, it will be difficult for the person reviewing the chart to deny the PA because he has already built the case within the chart.
Additionally, it is helpful to write all medications (including over-the-counter [OTC] artificial tears) by name and dose with specific information, such as the start and stop dates, adverse reactions, and reasons for the discontinuation of a medication.4
Utilizing dry eye codes for prior authorizations
Although there is variation in requirements for different payers, Dr. Wolfe mentioned that using a code of dry eye syndrome (H04.123),5 while appropriate in some cases, may not be specific enough to get PA approval. Consequently, for certain patients, he includes other International Classification of Diseases, Tenth Revision (ICD-10) codes pertinent to the diagnosis to build the complexity of the case.
Depending on the patient, this could include persistent epithelial defects (H18.899), superficial punctate keratitis (H16.143), and keratoconjunctivitis sicca (H16.223).5 In Dr. Wolfe's opinion, insurance companies generally view branded medications as being more indicated with added ICD-10 codes.
Dr. Dierker described this as “PA-proofing the charts” to provide comprehensive documentation that highlights the evidence to claim that a patient requires a specific medication due to a clear diagnosis that is backed with objective data.
Integrating PA processing into an optometry practice
Initially, Dr. Wolfe’s practice performed e-prescribing (eRx) in-house, meaning that if they received a prior authorization request, dedicated staff at the clinic managed them. However, with time they have found success with reassigning many of these administrative tasks to virtual assistants.
These virtual assistants complete PAs to the same quality as in-office staff, and they have been trained to know what information to look for and where in the chart. With this setup, the doctors tend to field fewer questions about PAs because clinic staff have also been trained in completing PAs, empowering them to answer questions, and establishing a filter before the question reaches the doctors.
Additionally, Dr. Wolfe’s practice utilizes forms with templates, allowing the virtual assistants to more easily identify specific information, as it is located in the same place for all patients. The practice also uses resources like Loom to record a short video explaining where to look in the chart and where the virtual assistants have to input the information for PAs.
Thus, in the case that a virtual assistant leaves, during the onboarding process, a new hire can watch the video to ensure that PAs are completed in a timely and correct manner.
Checking if pharmaceutical companies offer financial assistance programs
When prescribing medications for dry eye patients, Dr. Wolfe noted that typically he starts with branded medications because they can be cost-effective with coupons and certain insurance plans. Certain pharmaceutical companies offer discounts and product samples to help patients during the PA process as well as other cost-lowering initiatives.
When prescribing a medication, he explains to patients that if the treatment is too expensive, they can find alternatives that may cost less. Unfortunately, he can’t know exactly how much the co-pay will be until it is processed.
Conclusion
Dr. Wolfe predicted that PAs will be an enduring challenge for doctors as they are an effective cost-controlling mechanism for insurance companies. In light of this, it is critical for ECPs to establish an effective system for processing PAs.
He emphasized that this doesn’t necessarily require a significant amount of time or effort to manage and can notably improve the workflow. It is also critical to ensure that the PA processing system is well-integrated into the overall practice workflow and electronic health record (EHR) programs.
To conclude the discussion, Dr. Wolfe explained that PAs are not beneficial for patients, so it is incumbent on doctors and practice owners to understand the process and expertly navigate it with minimal stress for patients to help them get access to necessary healthcare.
