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Pharmacy Authorizations – Get the Approvals You Need Faster
Insurance companies usually require prior authorizations for medications that:
- have hazardous side effects
- are harmful when combined with other drugs
- are used only to treat certain health conditions
- are often misused or abused
- are prescribed to treat a non-life threatening medical condition, and
- are prescribed when less expensive drugs might be available
Getting these approvals involves a lot of paperwork and interactions with insurance companies, which can result in long wait times and delayed care for patients. That’s where our expert support comes in.
Get Speedy Approvals for High-Value Claims
Outsource Strategies International (OSI) provides efficient prior authorizations to support the delivery of timely care. By confirming drug benefits, we ensure that plan members and providers have a clear understanding upfront. Our team of experts:
- Provides pharmacy prior authorization services for all specialties.
- Works with all government and private insurances.
- Confirms drug coverage, copays, deductibles, and other plan details in advance of the patient visit.
- Helps you submit documentation that meet payer criteria and medical necessity along with pre-auth requests.
- Works to obtain speedy approvals for high-value claims, improving patient care as well as your cash flow.
Save Time and Focus on Your Patients
Our support helps you stay ahead of the curve, keeps your practice’s overall preauthorization process on track, and minimizes delays. Importantly, you can focus your time, effort and resources on patient care instead of prior auth paperwork and appeals.
Why Outsource Prior Authorizations to OSI?
Real-time verification via calls
Besides checking payer portals, our team calls up the insurance company to verify drug coverage. This results in faster approvals for medications and ensures that patients get the timely treatment they need.
Open communication
Our prior authorization specialists have robust relationships with payer representatives. They can provide clarifications in any issues arise and help you navigate the authorization process efficiently.
Expertise
Our specialists are knowledgeable about the pharmacy prior authorization policies of commercial and government payers. They can help you submit accurate and complete initial drug approval requests.
We serve all 50 states
Our Pharmacy Prior Authorization Process
Our experts closely monitor the status of the request till approval is received. They follow up with the payer and keep you informed of any additional requirements. We also provide appeals support for denials, helping you provide information to strengthen the case for approval.
1
Identifying the drug that needs prior approval
2
Collecting documentation
3
Evaluating payer-specific requirements
4
Preparing the request
5
Submitting the request to the payer
Identifying the drug that needs prior approval
Our insurance verification process identifies the prescribed medication that requires prior approval from the patient’s insurance plan.
Collecting documentation
The next step is collecting all relevant clinical notes, test results, and other supporting materials to demonstrate medical necessity. This includes the patient’s diagnosis, treatment history, and justification for the requested medication.
Evaluating payer-specific requirements
Our team evaluates the coding, documentation, or authorization request form requirements for the patient’s insurance plan.
Preparing the request
We help you fill out the authorization request form correctly and attach the supporting clinical documentation.
Submitting the request to the payer
The completed prior authorization form and documentation is submitted electronically to the insurance plan. The payer then reviews the request to assess whether it meets their coverage guidelines.
Benefits of Partnering with OSI
- Dedicated team
- Multi-level QA checks
- Proactive monitoring
- Timely reporting based on your needs
- Cost savings of 30-40%
- HIPAA-compliance
How Our Insurance Verification and Prior Authorization Services are Priced
Reduce administrative hassles and welcome efficiency with our skilled team supporting you. Choose from our flexible pricing plans based on your needs.
Full-Time Equivalent
In this model, services are billed based on the equivalent cost of a full-time employee (FTE) for a specified duration, usually monthly or annually.
Per Verification Billing
Like an FTE model, a person is dedicated to your practice. Perfect for a practice that is busy. They work as an extension to your business.
FTE/Per Verification Billing
This option is ideal for a practice that is unsure about their work requirements. This can have per request pricing for eligibility and other functions.
AR is only FTE
In this model, you will be charged a fixed monthly or annual fee based on the number of full-time equivalent staff required to manage your practice’s AR follow-up activities.
FAQs
What is pharmacy prior authorization?
Prior authorization is a process that involves obtaining an approval for a prescribed device, procedure, service, or medication from health plans before it is administered as designed. Pharmacy prior authorization is the requirement for approval from the patient’s health plan for a prescription drug. Insurers allow usage of appropriate medications only after thorough consideration of the patient’s health outcome and value to the plan sponsor. Services that require pre-authorization are approved based on clinical needs and will not be qualified for payment until the conditions for approval are met.
What information is typically required for a prior authorization request?
Common requirements include the patient’s diagnosis, treatment history, the specific medication being prescribed, dosage, and duration of therapy. Supporting clinical documentation may also be needed.
How long does the prior authorization process generally take?
Response times can vary widely among insurance plans, but generally range from 24-72 hours for expedited requests up to 14 days for standard prior authorization submissions.
How do you handle prior authorization denials?
When a request is denied, both you and your patient can appeal the decision. Our team can guide you through the appeals process and help you overturn the denial.
Why do health insurance companies require pharmacy prior authorization?
Health insurance companies use a PA as a means to essentially put a restriction in place to reduce unnecessary prescription drug use and cost of the service. Prescribed medications are approved after verifying the medical necessity to ensure it is the most economical option viable for the health condition. If a less expensive but equally clinical effective alternate is available after review, then the cost-friendly option is recommended by payers. It is an evidence-based process that minimizes overall medical costs to improve affordable healthcare access for patients. For example, if the physician prescribes an expensive drug, the insurance company may authorize it only if the physician can show that it is a better option than a less expensive medication for the condition.
What types of drugs require PA?
Each insurance company has a team of physicians, pharmacists and other medical specialists who review and research to create the list of newly approved medicines and existing medicines. They also consult medical practitioners to develop guidelines and administrative policies for pre-authorization. Insurance companies most likely subject the following kinds of drugs to PA:
- Brand name medicines that are available in a generic form
- Expensive medicines, such as those needed for psoriasis or rheumatoid arthritis
- Drugs used for cosmetic reasons such as medications used to treat facial wrinkling
- Drugs prescribed to treat a non-life-threatening medical condition
- Drugs not usually covered by the insurance company, but said to be medically necessary by the prescriber
- Drugs usually covered by the insurance company but are being used at doses higher than normal
Blue Cross Blue Shield requires prior authorization for those drugs that:
- have dangerous side effects
- are harmful when combined with other drugs
- should be used only for certain health conditions
- are often misused or abused
- are prescribed when less expensive drugs might work better
How long does prior authorization take?
Obtaining prior authorization for medication is a time-consuming process for physicians and their staff. According to AMA’s prior authorization survey 2023, physicians and their staffs spend 12 hours per week completing PAs. Typically, the pre-authorization process can range from a few days to weeks for a successful result, but may take longer in some cases. The time it takes for prior authorization to be successfully completed depends on numerous factors such as type of medicine, the payer’s rules, and the communication speed between the healthcare provider and insurance company. The main factor influencing the decision for PA approval is the quality of the healthcare provider’s documentation. Errors or discrepancies in the clinical notes, lack of information about previously tested medication or ambiguity about the state of patient’s disease could potentially lead to delay in the PA process. In the same AMA report, 27% physicians report that PAs are often denied. Further delays occur if coverage is denied and must be appealed. An appeal can take several days to process.
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