Training tips and opportunities: drug prior authorization

This is the fourth article in a series designed to educate health care providers and their staff about key aspects of the business and to let them know about the resources available to help them.

Prior authorization record reviews from across the country reveal some common trends in practice efficiency — and inefficiency — regarding prior authorization requests.

A practice’s prior authorizations requests for medications usually involve brand-name drugs for which there may or may not be a generic equivalent — or a drug that a patient has taken for years but that now requires reauthorization.

Tip: Practices should access the provider section of our website at bcbsm.com/providers to obtain prior authorizations whenever possible. Going online usually results in a faster response and helps you avoid wasting time while on hold with the telephone.

Most common errors
The most common errors when requesting a prior authorization and step therapy review are:

1. Not using the prior authorization form that is specific to the requested drug
2. Missing required clinical information or not completely filling out the prior authorization form
3. Missing member information; e.g., contract number
4. Not completing the diagnosis field
5. Not sending “chart notes” or “lab reports” that support use of the medication
6. Incorrectly marking a drug request as urgent when it is not
7. Not signing drug prior authorization forms

Guidelines to follow

Keep the following in mind:

1. Get prior authorization for specific drugs. Prior authorization is very important for all drugs ordered for patient use. For example, if you choose to administer a drug in the office that requires a prior authorization and it is later denied, your office may be charged for the cost of the drug. Some specialty drugs may cost $10,000 or more for one treatment. Denials can add up quickly, potentially creating time-consuming rework.
   
   
2. Keep urgent drug requests reserved for life-threatening situations or if it is the opinion of a physician with knowledge of the patient’s medical condition that a standard processing time may seriously jeopardize the health or the patient’s ability to regain maximum function. If the urgent request is incorrectly prioritized, short time frames apply and incomplete forms may render a denial due to lack of information.
   
   
3. Know what types of denials your practice typically receives. The errors listed above are just a few common causes of denials. These errors may cost your practice time and money filling in the missing information and resubmitting the request as an appeal. The more clearly you can identify any barriers that may cause your office to submit incomplete prior authorization requests, the better equipped you’ll be in addressing — and avoiding — them.
   
   
4. Create an appeals process or review the one you already have. When denials are caused by inadequate documentation, it’s recommended to appeal the claim and supply the documentation that was originally missing from the initial prior authorization request to support the medical necessity. Also, file the appeal within the required timeframe.