If you’ve ever been in an office and heard someone mention prior authorizations, it was probably followed by a loud groan from every ophthalmic technician within earshot. Prior authorizations (PAs) are a time-consuming process that can feel like a game of whack-a-mole between insurance companies, pharmacies, and patients.
Part of the nearly universal disdain of PAs lies in the relative thanklessness of the task; although I have received my fair share of kind thank-you notes and home-baked goods as appreciation, those niceties are unfortunately overshadowed by the countless angry phone calls and patients storming into the office demanding to know why their medications aren’t available yet.
There is no one tool or app that will always work for every case because the requirements of prior authorizations are different for each medication and change regularly, but there are ways to make obtaining PAs easier, faster, and more successful overall.
What is a prior authorization?
Healthcare.gov describes a prior authorization as “approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.”1
In translation:
- The ophthalmologist or optometrist sees a patient, diagnoses their condition, and prescribes treatment—such as a medication.
- This prescription is then sent to the pharmacy, where it is submitted to insurance for approval.
- Next, it is sent back to the doctor requesting confirmation of diagnosis and supplemental documentation to justify the diagnosis for the prescribed medication.
- Once this is submitted, which is necessary for the medication to be approved by the insurance company, the pharmacy may fill the prescription.
- Finally, the medication is dispensed to the patient.
If it seems complicated and time-consuming, that’s because it is. This process can take as little as a day or up to a month, depending on the complexity and the amount of correspondence required. A survey of physicians done in 2023 reported that their office staff spent an average of 12 hours a week completing PAs.2
To put that into financial terms, Salary.com claims the middle 50% of technicians are paid between $21 and $27 an hour,3 so if technicians are spending 12 hours a week on PAs, that means offices are spending, on average, $288 weekly. That’s $14,976 a year.
Every correspondence between office and pharmacy, pharmacy and insurance company, insurance company and pharmacy, and pharmacy and office slows down the process, so getting it right the first time is crucial.
The importance of PAs
The same survey of doctors that reported the amount of time spent on PAs also reported that 94% of doctors found that prior authorizations caused delays to necessary care, and 22% stated that the prior authorizations process “often” caused patients to completely abandon treatment.2
I’ve spent a fair amount of time illustrating that prior authorizations are expensive to practices, time-consuming, and tedious, but the fact is, unless an office is outside the network of all insurance companies, they’re a reality of modern healthcare.
The use of newer or brand-name ophthalmic medications with specific active ingredients or formulations is often necessary because of factors such as superior efficacy, fewer side effects, or less frequent dosing compared to older generation or generic medications. However, the approval of these medications often requires submitting a prior authorization.
Patient education is paramount
Patient compliance rarely relies on one factor, therefore a multifaceted approach is necessary for success.4 Getting patient’s medications covered by their insurance and in their hands as quickly as possible is one part, but setting the patient's expectations also plays a role.
Proper patient education can help avoid aggravation and possible abandonment of treatment. If the patient is being prescribed a brand-name medication, assume it will need a prior authorization and convey to the patient that it can take time to get the medication covered. Unfortunately, patients will often go to the pharmacy, learn that their medication is not covered, and assume that’s the final word.
Therefore, let the patient know before they leave the office that an insurance company requesting a prior authorization is not the same thing as a rejection. It is also important to mention that even though the doctor may have told them they have sent the medication to the pharmacy, the patient should not expect the medication to be ready for them that day.
If you can, give them a rough estimate of how much time it’s taken for other patients’ PAs to be approved (for example, blepharoplasties regularly take as many as 4 weeks to approve, whereas some dry eye medications take an average of 3 days). Tell the patient that if it goes beyond the estimated amount of time, you will contact them. When available, it may be appropriate to give samples, which will relieve some of the tension of waiting.
5 steps to avoid PA rejections
Luckily, the number of unique medications prescribed in eyecare is more limited than in general practices, and beyond that, most eyecare providers (ECPs) have their own preferred medications for the first line of treatment, making the variety of medications commonly used even less. That being said, with so many new ophthalmic medications being FDA approved—12 in 2023 alone—a lot of the medications used by ECPs are going to require a prior authorization.5
All of this is to say that ophthalmic technicians are faced with a lot of new medications to educate themselves on, and those medications will require more work to get them to the patient. It’s important to know what insurance companies are expecting when requesting a PA, and not just what to say but how to say it.
Here are five steps to help you get PAs right the first time.
1. Understand the role of AI
With the introduction of artificial intelligence (AI) into the process of approving or denying prior authorizations, words matter.6 It is estimated that just under 30% of PAs are being filed through AI currently.7
AI relies on explicit rules to produce consistent answers, but it is not currently capable of true logical reasoning, meaning it will not connect the dots within a PA, so we need to be more careful than ever to use consistent verbiage, and pay attention to which PAs are being accepted, and which ones are being rejected.
2. Utilize pharmaceutical sales reps
To get started, use the resources available to you. Pharmaceutical sales representatives, or “drug reps” as they’re more commonly referred to, are sales consultants who provide information about pharmaceutical products (and samples) to doctors and their staff.
Many of them have a financial stake in the medications they represent being prescribed. Perhaps for that reason, some offices are wary of drug reps, but when it comes to getting a medication covered, few people will have more knowledge on the subject, and more incentive, than the drug reps themselves.
Drug reps supply more than just samples, they are great resources when going through the PA process, especially in cases where you are experiencing a particularly difficult time getting approval, as they can often find ways to get patients their medications when all resources seem exhausted.
Here are a few questions your drug reps should be able to answer that will instantly improve approval rates:
- “What ICD-10 codes does [insert insurance company here] want to see?”
- “Are there any ICD-10 codes that people have found are overwhelmingly successful or unsuccessful?”
- “How many ‘failures of alternatives’ does [specific insurance company] require?”
- “Are there any specific tests or test results that are required for this treatment to be covered?” (e.g.,“What does the tear-break-up time for this dry eye treatment have to be for it to be covered?”)
If I encounter a PA rejection after speaking with a drug rep, I will call and give them the specifics of that case. Normally, they’ll want to know which insurance company it was, the justification, and most of the time, it turns out to be an error on my end, either word choice or lack of proper documentation, that can be corrected.
Over 83% of prior authorizations that are initially denied end up being approved with re-submittal, which means the vast majority of the time, the medications are warranted, there was just a fault found in how the PA was submitted.8 An insurance company may be looking for a more specific ICD-10 than was used, or prior therapy may not be clearly documented (more on that later).8
3. Know how to navigate ePA systems.
Most pharmacies and electronic medical records systems use electronic prior authorization (ePA) software to assist in getting the prior authorizations covered faster. This is where those questions you asked the drug rep will be valuable.
Some insurance plans require their own prior authorization forms, which can be printed from their websites. I recommend you keep these forms in a folder with as much of the repetitive information filled out as possible.
For example: I worked for a doctor who specialized in dry eye treatment, and they had a preferred first-line therapy, so along with the blank PA forms, I had copies with the name and sig of that specific medication already filled out, along with the doctor’s name, the location, and their NPI.
It only saved a minute of my time, but made the process feel a lot less tedious. All I needed to do was add the patient information, get the doctor to sign it, and send it in. It also helps to create a more uniform system, where all forms are guaranteed to have the correct information.
ePAs pearl: Always include an attachment of the patient's most recent relevant exam, as an omission of supplemental materials may automatically cause a prior authorization to be rejected.
4. Build relationships with pharmacies
The same attitude that is sometimes directed towards drug reps is often applied to pharmacies. Offices will sometimes become frustrated with pharmacies and treat them disrespectfully, and that, understandably, often engenders very little cooperation. Instead, build a rapport with your pharmacists.
Keep a list of common pharmacies and the pharmacist’s name by the tech station so when you need to speak with them and you can call them by name, that way, even if they don’t know you, they know you’re invested. Consider including them in your yearly office holiday cards, as this is a great way to show your appreciation.
5. Optimize supplemental material
To make your supplemental material more valuable, when a doctor is prescribing a new medication, be sure to add any prior failed alternatives, either in the medication history or the chief complaint. Getting into this habit will help prevent rejections.
Most insurance companies want at least one, if not two or three, alternatives attempted before they approve another medication. These do not always need to be prescribed medications, they can be over-the-counter remedies or in-office treatments like meibomian gland expression or intense pulsed light (IPL).
“Failure of Alternatives” can also mean that the patient is on a current therapy that they want to continue (say artificial tears or meibomian gland expression), but it isn’t doing enough. When prescribing for dry eye, be sure that the doctor is documenting relevant testing results in the anterior exam segment.
Tear break-up time, for example, is something that can be done at the slit lamp, it only takes seconds, and insurance companies value this information as a formal additional test when making their authorization decision.
Letters of medical necessity (LMN) are recommendations from the physician that may include information that is not clearly written in the clinical exam. In complex cases, the doctor may want to simplify why they are recommending this particular medication, or why they believe the alternatives are not an option for the patient. Especially if a prior authorization has been rejected, adding an LMN can give a resubmission substantially more weight.
An LMN is also something that can be written up in advance as an electronic document and then filled in to meet the specific needs of each patient, shortening the amount of time spent on each case.
How to follow up after PA submission
Once you’ve submitted your prior authorization, keep track of it. This is as simple as printing the authorizations out, writing the date on the back, and putting it in a folder at the tech station. Make a habit of checking on the PA requests every 48 hours.
The added benefit of printing out a completed prior authorization is that if there is any question as to if or when it was submitted, you have the hard copy to show that it was done, and it can be easily re-submitted without having to fill out an entirely new form.
If the prior authorization takes more than the expected time, contact the patient and reassure them you’re following up. Avoid off-loading blame on a pharmacy or insurance company to the patient. Instead, remind the patient that getting PAs accepted can be a complicated process, and running it by all the parties it has to pass through before it can be approved can take time.
Patients are technologically savvier than ever before, so even just sending a relatively generic text or email letting them know the PA is still in process will help cut down on phone calls and unannounced drop-ins.
In conclusion
Prior authorizations have never been easy, but by developing good relationships with your drug reps and pharmacists, stressing thorough documentation by the technicians and doctor, educating patients, and creating uniform submissions, consistent success is achievable in any office.
