The good news is that there are ways to expedite the process. And this guide covers 13 proven tips to speed up prior authorization for medication. We’ll also answer some questions about prior auth. for medications.

Making Sense of Prior Authorization for Medication

Prior authorization (PA) for medication is a process in which healthcare providers get approval from a patient’s insurance company before prescribing certain medications. This approval is usually required for expensive drugs, those with a higher potential for misuse, or medications that have lower-cost alternatives.

How to Obtain a Speedy Prior Authorization for Medication

Healthcare providers must obtain prior approval from payers for specific medications. For that, they must check the patient eligibility, medical necessity, complete the prior authorization form, and submit it to the insurance.

➜ Check the Eligibility of the Patient for the Medication: Verify that the patient is eligible for the requested medication under their insurance plan.

➜ Assess If Your Prescription Needs Prior Authorization: Determine if the medication requires prior authorization with due diligence. You can also consult with the insurance provider and RCM partner like BellMedEx.

➜ Complete the Prior Authorization Form for Medication: Fill out the specific form provided by the insurance company, including relevant details about the medication and patient.

➜ Submit the Prior Authorization for Medication Request: Send the completed form to the insurance company through their preferred submission method.

➜ Track the Prior Authorization Request: Follow up to ensure that the insurance company processes the request and make any necessary adjustments.

Despite these clear steps, you may face many challenges during the prior authorization process, depending on varying payer requirements, constantly changing rules, and a lack of transparency.

6 Common Challenges in the Prior Authorization Process

These challenges can lead to delays. That’s why, we must understand them quickly before we jump into speeding up the process.

1. Increased volume of prior authorization requests for medication.
2. Shortage of skilled staff members.
3. Constant updates to payer requirements.
4. The process itself is labor-intensive, requiring multiple steps.
5. High workloads and stress levels among healthcare workers.
6. A lack of transparency and understanding of the process.

Let us now jump on the ways to tackle these challenges and expedite medication prior authorization.

How to Speed Up Prior Authorization for Medication

Speeding up the prior authorization process for medication helps ensure that patients receive timely care. Reduced delays help healthcare providers improve patient outcomes, reduce administrative burdens, and increase practice efficiency.

These are 13 practical tips to accelerate prior authorization for medication:

1. Create a Master List of Medications That Require Prior Authorization
2. Document Denial Reasons Thoroughly
3. Stay Informed of Industry Standards & Payer Requirements
4. Assign a Dedicated Team for Managing Prior Authorizations for Medication
5. Use EHR, Software, and Automated Systems to Submit & Track Requests
6. Maintain Clear Communication With Payers and Patients
7. Implement Documentation to Speed Up Prior Authorization for Medication
8. Educate Patients About the Prior Authorization Process
9. Request Expedited Reviews from the Payer For Urgent Cases
10. Create a Follow-up Plan for Pending Requests
11. Streamline the Entire Submission Process
12. Be Vigilant With Payers that Take Longer to Respond
13. Hire a Prior Authorization Specialist for Medication

Let us understand each method in a little detail now.

1. Create a Master List of Medications That Require Prior Authorization

Creating a master list of medications that require prior authorization helps streamline the process. Keeping this list organized and up-to-date helps healthcare providers quickly determine which medications need prior approval before prescribing them.

This proactive approach helps reduce delays, as providers can verify authorization requirements ahead of time and avoid unnecessary back-and-forth with insurance companies. Payers provide you this list, but you should be constantly checking it for updates. Also, ensure all staff members know this list well to avoid missing approvals and help patients get care faster.

2. Document Denial Reasons Thoroughly

Thoroughly documenting the reasons for prior authorization denials for medication helps prevent repeat issues. When a request is denied, record the specific reason given by the payer, including any missing information or required documentation.

This helps healthcare providers understand common issues that may lead to denials and make necessary improvements for future requests. Recording the reasons for denials helps when challenging decisions, as it clearly shows why the request was turned down.

3. Stay Informed of Industry Standards & Payer Requirements

The prior authorization for medication can vary greatly between different insurance companies and over time. Staying informed about industry standards and changes to payer requirements is important for smooth processing.

Regularly review payer guidelines, participate in industry webinars, and subscribe to payer newsletters to ensure you’re always up-to-date on the latest changes.

4. Assign a Dedicated Team for Managing Prior Authorizations for Medication

Assigning a dedicated team to handle prior authorizations for medication can speed up the process. When a specific team or staff member is solely responsible for this task, they become more familiar with payer requirements and can address issues quickly.

Specialization helps improve efficiency as the team gains expertise in navigating the complexities of prior authorizations. This approach also helps prevent burnout and ensure that the medication approvals are smooth.

5. Use EHR, Software, and Automated Systems to Submit & Track Requests

Leverage technology to speed up the prior authorization process for medication. Electronic Health Records (EHR), specialized software, and automated systems can streamline the submission and tracking of prior authorization requests.

These tech stacks allow for quicker submission, better organization of patient data, and real-time tracking of the approval status. Automated systems can also send reminders for follow-ups, reducing the chances of missed deadlines or duplicate submissions.

6. Maintain Clear Communication With Payers and Patients

Clear communication with both payers and patients is one of the best ways to speed up the prior authorization, especially for medication. When submitting a request, ensure that all required documentation is included and provide any additional information promptly if requested by the payer.

Also, keeping patients informed about the status of their authorization and any potential delays helps manage their expectations and reduces frustration. Regular, transparent communication ensures positive relationships with both parties.

7. Implement Documentation to Speed Up Prior Authorization for Medication

Effective documentation ensures that prior authorizations for medication are efficient. Ensure that clinical data, including diagnosis codes, medical history, and rationale for prescribing a specific medication, is well-documented and up-to-date.

Having this information readily available helps prevent delays due to missing or unclear documentation. Well-organized and detailed documentation makes the process smoother for both healthcare providers and payers, reducing the risk of rejections or the need for resubmission.

8. Educate Patients About the Prior Authorization Process

Educating patients about the prior authorization, especially for medication, helps set realistic expectations and reduce their frustration. Many patients are unaware of the complexities and time involved in securing prior authorization.

And this can lead to confusion and dissatisfaction. Educating them about the process and potential delays ensure you’re on the same page. This transparency also creates a long-term relationship between you and patients.

9. Request Expedited Reviews from the Payer for Urgent Cases

Healthcare providers must request an expedited review to speed up the prior authorization for urgent medication cases. If a patient’s condition requires immediate attention, healthcare providers must contact the payer to address the issue.

Payers often have protocols for handling urgent requests, which can help accelerate the approval process. By the way, prior authorization is not required for emergency cases.

10. Create a Follow-up Plan for Pending Requests

Having a follow-up plan in place for pending prior authorization requests for medication ensures timely approvals. Regularly checking on the status of pending requests can identify any issues early on, allowing you to address them before they result in delays.

A systematic follow-up plan, such as following up every 24-48-72 hours, ensures that no request slips through the cracks. It also allows healthcare providers to stay informed about the progress of the authorization process.

11. Streamline the Submission Process

Streamline the submission process for medicinal prior authorizations to reduce delays. You can use standardized forms, ensure all necessary documentation is attached, and submit requests through electronic portals when available.

A streamlined process minimizes the chance of errors, missing information, or incomplete submissions that could delay approval. The more organized and consistent the submission process is, the quicker the authorization will be processed, ultimately leading to faster patient care.

12. Be Vigilant With Payers That Take Longer to Respond

Some payers may take longer to respond to prior authorization requests for medication. Be vigilant when working with these payers and proactively follow up on any delays.

Track the response times of various payers to identify which ones tend to take longer and take extra measures to expedite the process. This vigilance ensures that no request is forgotten, and that providers can address delays even before time.

13. Hire a Prior Authorization Specialist for Medication

Hiring a dedicated prior authorization specialist for medication is a proven way to speed up the process. A specialist with experience in handling prior authorizations for medication can manage the complexities of insurance requirements efficiently.

And that’s where BellMedEx comes in to help you track requests, resolve issues, and communicate effectively with both payers and patients. We ensure swift prior authorization for medication to reduce the administrative burden on your staff.

Schedule FREE Consultation

FAQs About Speeding Up Prior Authorization for Medication

In case we didn’t answer your question, you can contact us right away.

How long does prior authorization take for medication?

Most medication prior authorizations take 2-3 days, but this can change depending on the medicine type and insurance company. Some urgent requests might be approved within hours. For exact timing, it’s best to ask your insurance company directly.

How to check on a prior authorization for medication?

You can check your prior authorization status by calling your insurance company, checking their website or using their online portal (if available). The time it takes to receive a decision can vary depending on the insurer’s workload and internal processes. Regular follow-up helps you stay informed and fix any problems quickly.

What medications need a prior authorization?

Insurance companies usually require prior authorization for these medication-types:

• Brand-name drugs when cheaper generic options are available
• Age-specific medicines
• Cosmetic drugs
• High-dose medications
• Drugs with abuse potential
• Medicines not covered by insurance

Note: You can get the exact list of medication requiring prior authorization from your payers.

Prior authorization for medication denied, what to do now?

Follow these steps if prior authorization for medication is denied:

1. Find out why it was denied
2. Check for simple mistakes like wrong codes or spelling
3. Ask your doctor to provide more information if needed
4. Submit a new request or appeal the decision
5. Work with your doctor and insurance company to fix the issue

Speed Up Prior Authorization for Medication With BellMedEx

We can make your prior authorization process smoother and faster. Schedule a free consultation with us to learn how we can help your practice reduce denials and streamline your authorization workflow.

Schedule FREE Consultation

A healthcare provider’s top top priority is delivering the best possible care to their patients. However, the ever-present reality of insurance can sometimes create roadblocks. Prior authorization (PA), a process requiring approval from a patient’s insurer before providing certain services, is one such hurdle.

What is a Prior Authorization?

Prior authorization is a process mandated by some health insurance companies. It requires a doctor to get approval from a patient’s insurer before the patient is furnished with certain medical procedures.

This can include:

• Medications (especially specialty drugs)
• Medical procedures (particularly complex or expensive ones)
• Durable medical equipment (DME)
• Diagnostic tests (like MRIs)

Health insurance companies use prior authorization as a utilization management strategy. This means they want to ensure:

Medical Necessity: For example, “Is the requested service truly necessary for the patient’s specific condition? and/or are there potentially effective, less expensive alternatives?”.

Cost-Effectiveness: For instance, “Does the benefit of the service outweigh the cost? and/or could a less expensive option achieve similar results?”.

How Does Prior Authorization Work?

Prior authorization (PA), often a source of frustration for both patients and healthcare providers, is a process governed by insurance companies that requires approval before certain procedures, medications, or equipment can be provided.

Here’s a breakdown of how pre-authorization works:

Step 1 – The doctor examines the patient and decides on a treatment plan.

The healthcare provider examines the patient and determines the course of treatment, which might involve a specific procedure, test, medication, or medical device.

Step 2 – The doctor checks if the patient’s insurance requires prior authorization for the proposed treatment.

Here’s where the complexity arises. The burden falls on the provider to check the patient’s specific health plan policy (list of covered medications) to see if prior authorization is required for the planned treatment.

Step 3 – The doctor manually evaluates the prior authorization rules.

Unfortunately, clinical and healthcare billing systems are often not integrated. This means provider staff has to manually review the prior authorization rules for the specific insurance plan – a process filled with inefficiencies.

The process is tiring as sifting through paper documents, PDFs, or navigating various payer web portals, each with unique and frequently changing guidelines is time-consuming.

Step 4 – If prior authorization isn’t required, the doctor submits the claim to the insurance company, though approval isn’t guaranteed.

If the provider determines prior authorization isn’t necessary, they can submit the claim to the payer for processing. However, approval is not guaranteed.

Step 5 – If prior authorization is required, the doctor provides details for each treatment code and gets an authorization number from the insurance company.

If prior authorization is indeed required, the provider must gather more details:

1. Specific details for each CPT code (Current Procedural Terminology code) associated with the treatment.
2. A unique number is assigned by the payer specifically for this prior authorization request.

Step 6 – The doctor submits the prior authorization request and waits days or weeks for the insurance company’s decision: approval, alternative treatment, or denial.

The provider submits the formal prior authorization request and then enters a waiting period that can last days or even weeks, depending on the complexity of the request and the healthcare system’s capacity.

The burden falls on the provider to persistently follow up with the insurance company until a decision is reached such as approval, redirection to a different treatment option, or denial.

Challenges Faced During Prior Authorization and The Solutions

The prior authorization (PA) process intends to ensure appropriate healthcare utilization and cost management. However, denials can create frustration and delays for patients and providers.

These are some of the roadblocks to prior authorization approval and its potential solutions:

Cost Management: Health plans often favor less expensive medications or treatments with similar efficacy. A generic medication might be preferred over a brand-name one.

Medical Necessity Concerns: If the PA request doesn’t adequately demonstrate that the proposed treatment aligns with recognized medical standards for the patient’s condition, it might be denied.

Administrative Errors: Typos, incorrect billing codes, or missing information in the PA request can lead to rejection.

Coverage Issues: Procedures like cosmetic surgery or treatments not approved by the FDA typically require prior authorization, and may not be covered at all. Additionally, some medications might be covered under pharmacy benefits, while devices used with them might fall under medical benefits, requiring separate PA requests.

Missing Details: Insufficient information about why a specific medication or treatment is necessary can lead to denial.

Procedural Hiccups: If a health plan requires prior authorization for a non-emergency test and the test is performed before approval, the payer might deny payment, even if medically necessary.

The Solutions

Detailed and Accurate Documentation: Providing clear and comprehensive justification for the requested treatment, including relevant medical history and diagnosis codes, can significantly improve approval rates.

Electronic Health Records (EHR) Integration: Utilizing an EHR system that seamlessly integrates with insurance company systems can expedite the submission process and minimize errors.

Clear Communication with Patients: Keeping patients informed about the PA process and potential delays can help manage expectations and avoid unnecessary anxiety.

Collaboration with Payers: Healthcare providers can advocate for their patients and work collaboratively with payers to address any concerns or missing information in a timely manner.

Types of Prior Authorization

Prior authorization is more like a tool used by insurance payers to control the cost of services delivered by the providers. There are two types of prior authorizations:

1). Prior Authorization for Medication

Certain medications require prior authorization because of high risks for side effects and the sole purpose is to administer drugs that are safe and effective for their condition. These medications include:

• Medications with the potential to be abused, overused, or misused and have more cost-effective alternatives.
• Medications that carry a high risk of addiction
• Drugs for cosmetic use
• Rehabilitation
• Medical equipment
• Healthcare services for home 
• Diagnostic imaging
• Non-emergency surgery

Prior Authorization Process for Medication:

1. The prescriber orders medication for a patient to the pharmacy.
2. When the order is received, the pharmacist is made aware of the prior authorization status of the medication, and the physician or prescriber is made aware.
3. The physician’s office will start the pre-authorization process by collecting the information needed for approval using phone, email, or automated messages followed by long wait times until the PA is either approved or denied.

2). Prior Authorization for Prescription

Prior authorization for prescription is requested to ensure the cost-effective and appropriate use of prescription drugs. This feature allows providers to prevent improper use of certain drugs that may not be the perfect choice for a health condition.

Prior Authorization Process for Prescription

1. The pharmacist enters the prescription information into the system so if the patient’s plan requires prior authorization for the medicine the pharmacist receives an alert and will contact the prescribing doctor.
2. The doctor informs the patient if their plan allows for the drug use or not.
3. If authorization is already approved, the prescription is filled. If not, the doctor will need to prescribe an alternative.

3). Prior Authorization for Insurance

Prior authorization for insurance in medical billing means getting approval from the insurance provider before certain medical services are rendered to the patient. This is to ensure the insurance company will cover the costs.

Prior Authorization Process for Insurance

1. As a doctor, to get prior authorization for a patient’s procedure, first you have to determine if their insurance plan requires it for that particular service.
2. If so, we submit a request to the insurance provider, including details about the patient’s condition and medical necessity of the procedure.
3. Then we wait, often a week or longer, for the insurance company to review the case and determine whether they will authorize payment. It’s a tedious process, but a requirement by many insurers to avoid denied claims.

How to Improve the Prior Authorization Process?

Prior authorization (PA) is a necessary part of the healthcare landscape, but it can be a time-consuming task for both patients and providers.

Here’s how a healthcare provider can streamline the prior authorization process:

1. Documentation is Key:

Ensure all pre-authorization requests are accompanied by clear, comprehensive, and accurate documentation. This includes details about the patient’s diagnosis, justification for the specific medication or treatment, and any considered alternatives. Incomplete or poorly documented requests are more likely to be rejected, leading to delays.

2. Implement Automation:

Manual pre-approval processing can be a slow and error-prone affair. Consider implementing electronic health record (EHR) systems that integrate seamlessly with payer portals. This allows for faster and more accurate submission of prior authorization requests directly from the EHR.

3. Streamline Services Requiring PA:

Familiarize yourself and your staff with your payers’ specific pre-certification requirements. Develop a system to check for PA needs before services are rendered or prescriptions are sent to pharmacies. This proactive approach can save time and frustration down the line.

4. Maintain a List:

Create a comprehensive list of medications and procedures that require prior authorization for each of your major payers. Sources for this list can include copies of PA guidelines from payers or your EHR system’s flagging for medications on restricted tiers. Having this information readily available helps staff navigate the PA landscape efficiently.

5. Consider Specialist Support:

For high-volume practices, it’s crucial to delegate pre-authorization tasks to a dedicated team of specialists that can significantly improve efficiency. These specialists are well-versed in the intricacies of PA requirements and can handle the entire process, freeing up valuable time for you and your staff to focus on patient care.

By implementing these strategies, healthcare providers can significantly improve the prior authorization process. This not only reduces administrative burdens but also minimizes delays in patients receiving necessary treatments.

Frequently Asked Questions

1. What are some common services that need prior authorization?

Some common services that require prior authorization are:

• Hospital admissions
• Inpatient surgeries
• Some outpatient procedures
• Home medical equipment
• Advanced imaging machines such as MRIs and CT scans

Note: The services vary from provider to provider, therefore a patient should check with their provider the list of services that require prior authorization.

2. How do I know if a drug requires prior authorization?

Medications that require Prior Authorization are mentioned on the list of American Healthcare Preferred Drug List (PDL). So if a drug requires prior authorization, it will be represented with a “PA” next to the drug or you can contact the American Health Act (800) 872-8276 to find out if your medication requires PA.

3. What is medical necessity?

Medical necessity is the necessary care, services, supplies, or drugs needed for the prevention, diagnosis, or treatment of a condition on evidence-based clinical standards of care. We use medical records and recognized clinical guidelines to establish medical necessity.

4. Is Prior Authorization required for emergency services?

No, emergency services that need immediate attention do not require prior authorization and can be delivered without submitting PA requests.

5. What if I need a decision on my prior authorization request sooner than 10 days?

Emergency services generally do not require prior authorization. However, if it’s a matter of life or death for the patient you can request an expedited review of up to two business days. The request must include justification that the standard timeframe is not justified according to the current situation. The Medicare Administrative Contractor (MAC) identifies if the request is justified or not and proceeds accordingly.