Specialty Pharmacy Prior Authorization Services

RCM service providers love to quote from sources such as the 2016 AMA Prior Authorization Physician Survey and highlight facts about the burden of pre-approval. But specialty pharmacy practices rarely find a mention there.

As a leading specialty pharmacy prior authorization company, we have seen the impact that the PA process can have on the daily operations of a pharmacy. Optimizing the pre-approval process combined with accurate specialty pharmacy billing and coding leads to fewer denials and faster reimbursement.

Let us look at the various considerations that impact the pre-approval process

Coverage Review for Medications:

Certain medications may require advance notification and review to determine coverage under the member’s pharmacy benefit.

Additional information may be required from members or their healthcare provider for the payer to assess whether the medication is covered.

Criteria for Notification Program:

The criteria for determining benefit coverage under the Notification program are based on FDA-approved uses of the medication and medication labeling, considering both drug and diagnosis.

Medical Necessity Evaluation:

Medical Necessity assesses the clinical appropriateness of a medication beyond drug and diagnosis.

Factors considered include the condition being treated, severity, type of medication, frequency of use, and duration of therapy.

Step Therapy:

Step Therapy is implemented to encourage the use of cost-effective medications.

Members are required to try a lower-cost medication (step 1) before moving on to a higher-cost alternative (step 2).

Supply Limits:

Supply Limits are determined based on factors such as FDA-approved dosing, medical literature, and other supportive and analytic data.

• Quantity Duration (QD) limits define the maximum quantity of medications covered in a specified time period.
• Quantity Level Limits (QLLs) define the maximum quantity of medications covered per prescription or copayment.

Why Outsource to a Specialty Pharmacy Prior Authorization Company?

Let us now turn to some of the reasons which have prompted specialty pharmacies to outsource their pre-authorization requirements to specialists.

Increased efficiency:

20% higher approval rate for complex medications with outsourcing.

Reduced turnaround times for PA requests:

Freed up staff time for patient care and revenue generation.

Improved accuracy:

Reduced risk of denials and audits due to expertise in complex regulations. Standardized processes and technology for consistent execution.

Cost savings:

Reduced administrative costs through economies of scale. Improved revenue from faster medication access.

Data and insights:

Real-time data analytics to track trends and optimize workflows. Benchmarking against other pharmacies.

Additional Considerations:

Before you outsource to a specialty pharmacy prior authorization service, do consider these factors:

• Partner selection: Choose a reliable provider with expertise in catering to the specific needs of specialty pharmacies.
• Cost-benefit analysis: Evaluate the potential cost savings and revenue improvements against service fees.
• Technology integration: Ensure seamless integration of the provider’s platform with your existing systems.

To summarize, outsourcing specialty pharmacy prior authorization service significantly improves the efficiency, accuracy, and financial performance of pharmacy practices.

Get Complete Support in Prior Authorization for Specialty Pharmacy Practices

As a leader in healthcare lifecycle management, we have been helping providers and suppliers across the US get Prior Authorization even when medical necessity is hard to determine. We accomplish this with a thorough understanding of payer requirements and detailed information in the requests.

For over two decades, we have worked with most payers out there both private and public, including but not limited to, Medicare, Medicaid, Tricare, Kaiser Permanente, Elevance, HCSC, UnitedHealth, Cigna, Humana, CVS and many more.

Check out some of the benefits that our clients appreciate:

• Quick turnaround times; averaging 24 hours to prepare for and initiate an authorization request for 97% of the cases
• Dedicated Specialty Medication preauthorization specialists for every project
• Strong payer relations
• Contact centers and medical answering services
• No-binding contracts
• 30-day free transition
• Industry best cost per Full-Time Equivalent (FTE)
• Trustworthy references and client testimonials available on request
• Deep domain knowledge with experience spanning almost two-decades
• Other RCM services like A/R management, payment collection and more

Our tenacity in reaching out to payers sets us apart from other specialty pharmacy prior authorization companies. We believe that no denials are necessary, and patients should get the medication they need, when they need it.

Say no to denials and experience faster prior authorization approvals with our dedicated support. Speak to our experts today and revolutionize your prior authorization experience.