‘Nobody understands what is going on’: Knowledge key to navigating prior authorization

AUSTIN, Texas — Understanding the laws governing prior authorization is one way rheumatology professionals can ensure patients receive the drugs they need on time, a presenter said at the 2023 Rheumatology Nurses Society annual conference.

“Prior authorizations originally came about to save money,” Alicia Sullivan, vice president of the National Organization for Rheumatology Management (NORM), told attendees. “But it is really a way for insurance companies to lower what they have to spend.”

Prior authorization is also a way for insurance companies to delay treatment, so they do not have to cover medications, she added.

“Seventy-five percent of denials won’t even be fought,” Sullivan said. “People will try something else or give up.”

The good news is that because rheumatology medications are often used off-label, rheumatology professionals tend to be savvier about the procedures than other providers. “Rheumatologists tend to fight,” Sullivan said. “They know a little bit better how to navigate the system.”

However, not all rheumatology professionals are as familiar with the system as they could be, so improving understanding regarding the details of prior authorizations can be beneficial to getting patients the medications they need.

Insurance carriers commonly require step therapy, where a patient must try one medication before they can move on to others. Obtaining prior authorization for the second or third step medication can be challenging.

A similar issue is non-medical switching.

“They will tell a patient, ‘You have to try another drug even though you have been stable on this drug for 10-plus years because we prefer this other medication,’” Sullivan said. “They tell patients, ‘We don’t have a medical reason for it but you have to do these things first.’”

Proof of medical necessity for a drug being administered is also usually required for prior authorization. If necessary, the rheumatologist must also help the patient enroll in assistance programs.

At that point, there are a number of questions to consider, according to Sullivan.

“Do they have coinsurance? Do they have a deductible? Do they have patient assistance? Is there free drug available? Is there a bridge program?” she said. “We try to figure out what is best for the patient financially.”

The insurance carrier then denies or approves the authorization once supporting documentation is received. If the authorization is approved, then the patient can continue treatment.

“If they are denied, you need to re-think the patient benefits to see what is available and what will work,” Sullivan said.

Of particular concern for Sullivan is the timeline of all of this activity.

“In 2005, it was 2 minutes on the phone,” she said. “Now, it might take 3 to 4 weeks just to get a refill. Nobody understands what is going on anymore.”

Attendees were encouraged to familiarize themselves with the existing legislation regarding prior authorization at both the state and federal levels. Laws can pertain to step therapy exemptions or mandated response times. Insurance may also mandate that physicians be licensed in the state where the medication is being administered.

On the positive side, some states disallow retroactive denials. In addition, other states require that authorization must cover a full year for patients with chronic conditions or that insurance carriers must honor previous authorizations for at least 90 days.

“Legislation varies from state to state,” Sullivan said. “You have to be a little tenacious.”

Meanwhile, atient and professional advocacy organizations have managed to move the needle on many fronts, including legislation.

“There are actually good things happening for the first time in 10 years,” Sullivan said. “People are actually understanding and working together.”

Some of the advocacy groups working in the prior authorization space include NORM, the Coalition of State Rheumatology Organizations andthe American Medical Association.

However, perhaps the most important entity in the equation is the patient, according to Sullivan.

“From the beginning of the process, I will get the patient involved,” she said. “The patient is the customer. If we are doing our side, and the patient is doing their side, things can happen.”