The prior authorization process is very difficult for the rare drugs. You need to verify patient eligibility, collect important documents and then submit PA request. Now, you may have this question: What are the complex PA challenges, and what are the solutions to them? We’ll get to the answer, but before that, let’s dive into the PA process in specialty pharmacy billing.
What is the PA Process in Specialty Pharmacy?
Prior authorization is a major component of a pharmacy billing cycle. It is highly important to know during the patient eligibility process which drugs require a PA process. But it is not that easy. This approval completely depends on the insurance company’s PA process. It has been observed that there are multiple reasons for which claim denials occur. These reasons include insufficient documentation, coding errors, and patients’ insurance coverage discrepancies. Still didn’t get it?
For example, a patient having Humira may receive prior authorization for the given drug. But the claim can be denied if the patient’s documents are not correctly submitted. But is it the only challenge the providers face? No, that’s not the issue. Hence, let’s get to the challenges one by one.
Prior Authorization Challenges
One of the main challenges is assigning the correct pharmacy codes. It is no secret that you need to correctly document the procedures to receive timely authorization. Hence, as there is a vast number of complex codes available, the documentation process is highly challenging.
Each insurer has separate PA rules. Moreover, the insurance companies are increasing the number of drugs which require a PA process. It makes the prior authorization a very time-consuming process. Always remember that as a specialty pharmacist, your job is to provide the best possible care to the patient. You need to outsource the PA process.
Sometimes, even if a procedure is planned well in advance, the PA may lead to denials. But whenever a patient receives necessary treatment, maybe then they need a different drug than what is prescribed. The chances of denials are higher than in the approval process.
Strategies to Improve Prior Authorization
Now that you have understood the challenges, how can you solve those? Here, the specialty pharmacy billing companies come to rescue. They have proper and adequate resources to scale every need of small to large-scale healthcare practices. Let’s dive into how they can help you.
Assigning dedicated staff members
To excel in the PA process, you need experience. Now, not every staff member has the experience because they are mostly busy with the healthcare operations. The outsourced companies come in with dedicated experts. These experts know everything about the PA process to make sure no claim denial occurs.
Maintaining a Master List
You need to have a master list of medications and procedures needing PA. The difficult process comes when the outsourced experts update the list. Apart from that, you need to stay updated on the latest payer rules to make sure that your master list is updated.
Thorough documentation
Do you know one of the most underrated reasons PA processes fail? It’s the inadequate clinical documentation. The specialty pharmacy billing companies come in, who know all the complex nuances of the documentation procedure. Thorough documentation is highly important.
Timely follow-up
Tracking the PA process regularly and following up makes sure the claims don’t get denied. Sometimes, payers can miss several things. So, the billing staff needs to follow up to streamline the claim submission process.
Appealing denials
A well-organized case is essential when appealing a denied PA. You need to include all the documentation and clinical information to make sure no further claim denial occurs.
How Can You Choose the Right Company?
Do you know what’s one of the worst things pharmacies face? It is failing to find the right balance between the billing process and the patients. You need to have a clear plan to streamline your billing process. Apart from that, there are several areas in which the outsourced specialty pharmacy billing company can help you. These are managing patient records, creating entries of patient demographics, prior authorization, refill management, AR follow-up, and payment posting.
Outsourced experts can significantly reduce your operational costs by 80%. They provide 99.9% accuracy in a closely audited operation. Moreover, these experts have proven expertise in handling the best pharmacies. Furthermore, these companies also provide dedicated account managers free of cost. Apart from that, they also don’t have any binding contracts or restrictive clauses.
These companies provide pre- and post-billing solutions. These include patient insurance verification, prior authorization, documentation, claim submission, denial management, and virtual office assistance. Moreover, they also help with different specialties such as DME, orthotics and prosthetics, urgent care, gastroenterology, infusion, and many other specialties. So, if you want to streamline the billing process, it can be a feasible option to outsource a specialty pharmacy billing expert. So, take this step today so that you don’t face any issue.
