Prescription Medication Prior Authorization Explained

This video provides an in-depth explanation of the prescription medication prior authorization (PA) process, detailing the complex, multi-step journey a prescription takes from a prescriber to a patient when a PA is required. Dr. Eric Bricker, the presenter, systematically breaks down each stage, highlighting the numerous inefficiencies, potential for error, and significant delays inherent in the current system. His analysis underscores how this administrative burden not only frustrates healthcare providers but also poses serious risks to patient health, framing the process itself as a "public health threat."

The discussion begins with the prescriber's initial challenge of determining if a medication requires PA, a task complicated by the vast and varied formularies across different insurance carriers and Pharmacy Benefits Managers (PBMs). For instance, CVS alone lists approximately 495 medications requiring PA. The submission methods are then explored, ranging from archaic fax machines, which often involve lengthy, standardized forms (e.g., Illinois' 40-field form), to various electronic prior authorization (e-PA) routes through intermediaries like CoverMyMeds and Surescripts, or direct PBM portals. Critically, most physicians are forced to use a combination of these methods, adding to the administrative complexity.

Upon receipt by the PBM, the process continues with a prior authorization technician manually abstracting information from faxes into their system, a step prone to data entry errors. Subsequently, a prior authorization pharmacist reviews the request against specific criteria, which can include patient age, lab values (e.g., blood glucose, BMI for medications like Risperdal), and even the prescriber's specialty (e.g., a dermatologist for Retinol). The pharmacist's role often involves independent clinical judgment, introducing a degree of subjectivity. If denied, the request is sent back to the prescriber, who can provide additional clinical information or escalate the decision to a medical director, prolonging the process further. The video concludes by emphasizing the severe consequences of these delays, citing physician surveys indicating that 24% of PAs result in adverse patient events and 16% lead to hospitalizations, while prescribers spend an average of 14 hours per week on PA-related tasks.

Key Takeaways:

• Complex PA Determination: Identifying whether a prescription requires prior authorization is a significant initial hurdle due to the sheer volume (e.g., ~495 medications on CVS's formulary) and variability of requirements across different insurance carriers and PBMs.
• Inefficient Submission Pathways: Prescribers must navigate a fragmented system involving fax machines (with lengthy forms, e.g., 40 fields in Illinois) and multiple electronic portals (CoverMyMeds, Surescripts, individual PBM sites), often using a combination of these methods, which is highly inefficient.
• Manual Data Entry and Error Risk: Prior authorization technicians at PBMs frequently abstract information from faxed forms and manually enter it into their systems, creating opportunities for transcription errors that can lead to denials and further delays.
• High Workload and Subjectivity for PA Pharmacists: PA pharmacists are often expected to review a high volume of cases (e.g., 60 cases per 8-hour day, or one every 8 minutes), and their decisions can involve a significant degree of independent clinical judgment, leading to potential inconsistencies.
• Diverse and Specific Denial Criteria: Prior authorization requests can be denied based on various criteria, including patient age (e.g., Retinol for acne), specific lab values (e.g., blood glucose and BMI for Risperdal), and even the specialty of the prescribing physician (e.g., requiring a dermatologist for Retinol).
• Significant Delays in Patient Care: The PA process typically takes 1-3 business days, with urgent requests sometimes taking up to 24 hours. This often results in delays in treatment, with surveyed physicians reporting that half of PA requests cause a delay in care.
• Direct Link to Adverse Patient Outcomes: The delays caused by prior authorizations are not merely inconvenient; 24% of surveyed physicians reported that the process led to adverse health events in their patients, and 16% stated it resulted in hospitalizations.
• Substantial Prescriber Time Burden: Physicians spend a considerable amount of time on prior authorizations, with surveyed doctors reporting an average of 33 PAs per week, consuming about 14 hours of their time—time that could otherwise be spent on direct patient care.
• E-Prior Authorization Efforts are Incomplete: While electronic prior authorization (e-PA) is an ongoing effort to streamline the process, it is not yet universally adopted or fully integrated, meaning the inefficiencies of manual and hybrid systems persist.
• The System as a "Public Health Threat": The cumulative effect of these inefficiencies, delays, and patient harms leads the presenter to characterize the current healthcare delivery and payment mechanism, particularly the PA process, as a significant public health threat.

Tools/Resources Mentioned:

• CoverMyMeds: An electronic prior authorization solution, a subsidiary of McKesson.
• Surescripts: An intermediary for electronic prescribing and prior authorization, co-founded and co-owned by CVS and Express Scripts.
• PBM Direct Electronic Portals: Many PBMs offer their own direct electronic submission methods for prior authorizations.

Key Concepts:

• Prescriber: A general term for healthcare professionals authorized to prescribe medications, including doctors, nurse practitioners, physician assistants, podiatrists, and dentists.
• Pharmacy Benefits Manager (PBM): A third-party administrator of prescription drug programs for commercial health plans, self-insured employer plans, Medicare Part D plans, and other government programs.
• Formulary: A list of prescription drugs covered by a health plan, often indicating which medications require prior authorization.
• Prior Authorization (PA) Tech: A technician at a PBM responsible for processing prior authorization requests, often involving manual data entry from faxed forms.
• Prior Authorization (PA) Pharmacist: A pharmacist at a PBM who reviews prior authorization requests against clinical criteria to approve or deny them.
• Medical Director: A physician at a PBM who reviews escalated prior authorization denials and can override previous decisions.
• E-Prior Authorization (e-PA): The electronic submission and processing of prior authorization requests, aimed at streamlining the traditional paper-based or fax-based methods.

Examples/Case Studies:

• Retinol (Retinoic Acid) for Acne: Used as an example where PA criteria might include patient age (e.g., covered for under 18 but not over 18) and require the prescriber to be a specific specialty, such as a dermatologist.
• Risperidone (Risperdal): Used as an example of a psychiatric medication where PA criteria might require specific lab values (e.g., blood glucose levels) and patient metrics (e.g., BMI) due to potential side effects like high blood sugar and weight gain.