Ways Specialty Pharmacy-specific Prior Authorization Services Help Your Organization Stand Out

The current state of regulations and policies concerning prior authorization services for specialty pharmaceuticals is complicated and rapidly evolving. The increase in the number of payers implementing prior auth requirements for these expensive and complex drugs, is adding to the pressure on specialty pharmacies to secure authorizations on time to not delay patients’ access to critical drugs.

Apart from the volume and time-related pressures, existing procedural challenges make securing preauthorization for specialty medicines inconvenient and burdensome.

Existing Challenges with The Specialty Medication Prior Authorization Process

The utilization management practice of prior authorization is riddled with complexities, irrespective of whether it is for prescription drugs, specialty medications or medical procedures. These issues call for a streamlined and specialized approach, without which, delays in securing authorizations and denial of coverage become painfully common. Some of the most common challenges that specialty pharmacies face with the prior auth process are:

• Growing list of prior authorization requirements for specialty medications

As payers continue to add new prior authorization requirements for specialty pharmaceuticals, pharmacies that supply specialty drugs often find it difficult to keep up, leading to significant delays, denial of coverage and in many cases, prescription abandonment by patients.

A survey by the American Society of Health-System Pharmacists found that the “average time to secure prior auth for specialty drugs is 18.5 days, with the denial rate ranging from about 18% to 20%”.

• Time-consuming and labor-intensive nature of the specialty drugs prior authorization process

Specialty pharmacies are required to collect extensive documentation from both patients and prescribers before submitting them to the insurer. This process can take days or even weeks, delaying

patients’ access to critical medications. A study by the American Pharmacists Association highlights this issue and mentions in their report that “processing prior auth requests take about 2.5 hours on average”, which if reduced, can free-up time for pharmacy staff to focus on other crucial operational functions.

• High denial rates for specialty drugs prior-authorization requests

Complicated requirements and procedures in securing prior-authorization for specialty drugs leave plenty of room for errors and misses, which lead to denial of coverage. A study by the National Alliance of Specialty Pharmacy found that “over 1 in 5 PA requests are denied coverage” due to various issues ranging from lack of communication between payer and pharmacies to complex documentation requirements.

Opportunities

Besides posing challenges, the intricacies of the specialty medication preauthorization process present opportunities too. Specialty pharmacies can stand out from their competitors by overcoming these challenges and improving patient, provider and payer communications. A few optimization opportunities arising out of these challenges, that can help a specialty pharmacy stay ahead of its competitors are:

• Lower patients’ waiting time in accessing specialty drugs
• Master and stay updated about changes in pre- authorization requirements
• Establish efficient communication channels to link patients, prescribers and payers

How a professional specialty pharmacy prior authorization service can add considerable value

A trusted healthcare revenue cycle management company with proven expertise in securing prior authorizations for specialty drugs can reduce the prior auth burden off specialty pharmacies in many ways.

From leveraging the services of certified and experienced prior authorization specialists to reducing labor costs and benefits by at least 50%, specialty pharmacies can unlock serious competitive advantages by partnering with a reliable specialty medication prior-authorization service provider.

Below are some of our many benefits and value-added offerings that our clients (both large and small) appreciate:

• Competitive, customizable and flexible pricing models
• Quick turnaround times; averaging 24 hours to collect, submit and secure authorization for 97% of the cases
• Dedicated specialty medication preauthorization specialists for every project
• Strong payer relations
• Contact centers and medical answering services
• No-binding contract
• 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 revenue cycle optimization value-added services like A/R management, payment collection and more

For more information about our expertise in securing prior authorization for specialty medications, or to know more about our flexible, volume-based pricing models, please contact Sunknowledge Services Inc., a reputed end-to-end healthcare RCM company, helping healthcare providers reduce costs, maximize revenue and drive operational efficiencies.