Strategies enable greater success in prior authorization requests

Key takeaways:

• Be meticulous in checking the accuracy of your applications before submitting them.
• Use resources from the ACAAI and other parties to improve your applications.

BOSTON — Diligence and persistence are keys to success in prior authorization in allergy and asthma care, according to an abstract at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.

Assigning the right people to the task is essential as well, Amy Palmer, RN, national director of biologics at AllerVie Health, said during her presentation.

Best practices

One of the easiest things to fix, Palmer said, is ensuring that whoever manages prior authorizations completes the required fields.

“A lot of people still use paper forms, and that is perfectly fine,” Palmer said. “When we’re using those paper forms, we want to make sure that we’re double checking our work before we submit information over to the insurance company.”

Information must be legible, she continued.

“It doesn’t do any good if they can’t understand what the lab says,” Palmer said. “If that nine doesn’t look like a nine, that may make a big difference in getting the approval.”

Whether forms are paper or electronic, practices should include exactly what the insurance company is requesting, and nothing more, she added.

“Some people want to just put everything on a PA form, and payors are not going to read it,” she said. “We don’t need to throw the book at them. We need to highlight what they’re actually asking for, what they want, and then just give them the necessities.”

Some systems allow for attachments. Even then, she said, practices should use restraint and include notes in a bullet point format. Palmer also noted the benefits of electronic portals, which look for errors during the submission process.

“Then what do we do once we receive that approval?” she asked.

Tools like authorization trackers assist with electronic records, she said.

With phone authorizations, she continued, staff should get the phone call’s reference number, which usually is different from the authorization’s reference number. Further, staff should verify the drug information, since many drugs use different dosage forms.

“That can make a difference at the pharmacy or when you go to administer it,” Palmer said.

Staff additionally should review the information they get back from the insurance company to ensure it covers the entire treatment period that is being approved. A copy of the approval should be included in the patient’s record as well.

“Utilize your resources,” she added.

The ACAAI’s Prior Authorization Toolkit includes tips for completing prior authorization forms. Also, it can generate templates for letters of appeal.

“These letters are customizable, so you can enter the patient’s information,” she said.

Plus, the letters in the toolkit include literature references, which payors often require for appeals.

“It can really save you time,” she said. “And then it can teach your staff how to generate a lot of those letters themselves.”

Drug manufacturers and third-party vendors offer similar support.

“Are we going back to allowing our manufacturer supports that are in our office, knocking at our doors wanting to help, to help us?” Palmer said.

These representatives can educate the staff about prior authorization procedures too, she said, noting that some employees might not even know what a prior authorization is.

“When we’ve been in this world for a long time, we make assumptions about what people would know from the front office to the back office,” she said.

“They need to be able to get copies of insurance cards and pharmacy cards,” she continued. “If they don’t understand the why, sometimes it’s really difficult for them to want to do that. And so, if we can explain that to them, then that’s helpful.”

Getting started

One of the biggest keys to success is knowing where to get started, Palmer said.

“Am I going to the medical policy? Am I going to the patient’s insurance cards?” she said. “What are the medical benefits? What are the pharmacy benefits? And how does that work among our practice? What does that look like?”

Staff should know the differences between traditional Medicare and Advantage, pharmacy and commercial plans, Palmer said.

“You may have the option of buy and bill. You have patients that have pharmacy only plans. You have patients that have the commercial plans,” she said.

When staff sits down with a new prior authorization form, Palmer said, they should know whom they are sending it to.

“There’s a lot of form options, and if you’re filling out the wrong group,” she said, “then we’re also not diminishing our risk.”

Knowing whether the drug is going to be administered in the office, at home or at an alternate site of care also is important.

Medical benefits may cover in-office administration of drugs provided via buy-and-bill programs. In-office treatment provided by specialty pharmacies may be covered by medical and pharmacy benefits. Pharmacy benefits only cover at-home injections, whereas medical and pharmacy benefits alike may cover administration at alternate sites of care.

Of course, Palmer said, it is a lot to learn, and these requirements change often.

“Just when we sometimes feel like we’re getting it, then they decide to make another change,” she said.

Palmer encouraged physicians to try to keep up with these changes via notifications from payors and communicate with other practices about them.

“Be willing to share that information,” she said. “If you’re seeing a big payor change, then it’s helpful to share with others.”

By keeping up with these changes, Palmer said, practices can proactively ensure there are no delays in patient care and spare themselves from the financial risks of updates of which they are not otherwise aware.

Appropriate staffing

“The other thing that I think really sets us apart in what we can do to help with prior authorizations is really investing in our team, whether that’s a single point of contact or whether that’s a team of people that’s handling prior authorizations,” Palmer said.

“They have the experience to be able to know what to do,” Palmer said. “They know, looking at the patient’s insurance up front, ‘Who am I going to go to? Where’s the patient going to go?’ Based on that drug, you can jump right into the prior authorization forms.”

Palmer called this expertise “a huge benefit” in achieving success in prior authorizations.

“We’re not getting a ton of denials back,” she said. “They’re doing things that work within their practice, efficiently and effectively.”

In addition to completing all required fields in forms and verifying that all the information is clear, legible and relevant, she said, the staff assigned to prior authorizations should follow up on their status and communicate with other members of the team and with the patient.

“It helps with patient satisfaction,” Palmer said.

Palmer also advised practices to work ahead of the expiration date by ensuring that patients have follow-up visits and renewing records for renewal criteria. As insurance companies manage increasing numbers of renewal requests, she continued, they are narrowing the timeframe for recent visits.

“It used to be a lot of ‘recent visits’ were within a year,” she said. “That’s decreased down to 6 months for patients. So, we want to make sure these patients are on schedule and that they’re keeping those follow-ups.”

When expiration dates are happening within the next month, Palmer said, practices should reach out to patients to get them back in the office for the assessments that are necessary to support the prior authorization documentation and continued care.

Again, Palmer emphasized that these documents should be included in the patient’s records and that experienced members of the team should be able to do so.

“It’s easy to find it you need it,” she said. “We may need that for a claim denial in the future, or maybe just to verify how many doses were approved.”

Filing appeals

Palmer expressed hope that these strategies will minimize denials but was upfront in saying that they will still happen. She said that experienced members of the team should know how to submit appeals and not be afraid to do so.

“They’re utilizing the resources within the College and knowing those templates,” she said. “Then they’re going back.”

These team members should track the reasons why claims are denied so they can use this information to prevent future denials, Palmer said.

“Maybe it was just a change in the criteria,” she said. “We can go to the providers and say, ‘Hey, look. This was not required, but it’s new criteria.’ Let’s start addressing that before we start working on new patients or renewals.”

By being proactive like this, Palmer said, practices can see decreases in their denial rates.

When denials continue anyway, she added, practices should not give up.

“Keep trying. You’re making a difference in your patients’ lives,” she said. “Sometimes that feels hard, but a ‘no’ can just be a ‘not yet,’ and that may mean you go back and look at the denial.”

Palmer encouraged practices to then make whatever corrections they need to make, using available resources as appropriate, and resubmit the claim.

“Continuously work on making sure that you’re able to get patients approved,” she said. “Just don’t give up.”

Palmer recounted one claim that was rejected by a payor four times.

“They kept giving me the chance to appeal it, so I was going to keep appealing,” she said, adding that there are patients on the other end of this paperwork and that these efforts can change their lives. “With that fifth appeal, they gave us an approval.”

Putting strategies into practice

Palmer encouraged practices to always verify that medical and pharmacy insurance is both up-to-date and accurate. Practices also should always ensure they have the correct forms and review all clinical information before beginning a prior authorization request.

“It’s a lot of things that can happen with prior authorizations,” she said. “But if we’re utilizing our resources, and you know where to start, it really helps start you out on the right path, and we don’t get lost along the way.”