Taking the pain out of prior authorization denials
Answers in Practice
By Emily Margosian, Assistant Editor, January 1, 2020
Dermatology World talks with Martina Porter, MD, at Beth Israel Deaconess Medical Center, about how she has mastered the prior authorization appeal process. Dr. Porter is co-director of the Clinical Laboratory for Epidemiology and Applied Research in Skin (CLEARS) for the department of dermatology at Beth Israel Deaconess Medical Center.
DW: Tell me about your practice.
Dr. Porter: I work at Beth Israel Deaconess Medical Center in Boston, which is an academic center. We have about 24 full-time dermatologists in our department, and we see all types of patients at our practice, including complex medical dermatology and cosmetic patients.
DW: How did you hear about the AADA’s prior authorization appeal letter tool?
Dr. Porter: While I was doing my residency and fellowship, I was working in a clinic that was primarily seeing patients with psoriasis and hidradenitis suppurativa — so we had a lot of prior authorizations (PAs) to do, particularly for biologic agents. I was doing the bulk of the appeals for prior authorization denials — calling insurance companies and conducting all the peer-to-peer reviews.
I saw an email from the AAD advertising the new PA tool in March 2017, but at the time, I thought it was for submitting prior authorizations. I didn’t realize it was a letter for prior authorization denials until months later when I happened to look at the AAD’s website. I then spent a fair amount of time generating different templated letters for all the diseases and medications available through the tool to assess the quality of the letters, which was impressive, and I started using them. I think one of the best features of the letters is that they have all the literature citations, which are really helpful when we’re trying to get medications approved for patients.
DW: How do you use the appeal letter generator in your practice?
Dr. Porter: Our institution hired a dedicated pharmacy liaison for our department in August 2017, and she handles all of our prior authorizations for the entire department, including the initial prior authorization submissions and the appeals. After we got her access to the AADA tool, she started using the letters regularly for certain cases. The prior authorization tool only covers FDA-approved indications, so that is the main limitation of the tool, as many of our PA denials are for “off-label” indications. However, our pharmacy liaison will always try to use the PA tool first, and if no letter is available, then she will often alter generated letters for approved indications and change some of the literature citations and text for these off-label meds. The PA tool is now a routine part of our pharmacy liaison’s practice because it’s faster than calling the insurance company or writing her own letters.
DW: What results have you seen as far as approval rates after you started using the AAD’s tool?
Dr. Porter: We have hundreds of prior authorizations each month, and I conducted a research study to see what our approval and denial rates were for different diseases and medication indications. Over the studied three-month period, our pharmacy liaison had a higher approval rate using the AADA PA tool letters than with traditional appeal letters. While this was not statistically significant, it does show that the AADA prior authorization tool is an effective measure for appealing prior authorization denials while also being time-efficient and easy to employ.
DW: What was your experience working with AAD staff to get the tool up and running for your pharmacy liaison?
Dr. Porter: The AAD allows practice staff to maintain their own individual AAD accounts, linked to an AAD member’s account in order to access the tool independently. The AAD support team was very helpful in setting this access up for us in less than a day. Overall, the AAD has been really responsive. I do a lot of research for hidradenitis suppurativa — which was a disease they didn’t originally include despite the fact that there’s a FDA-approved indication for adalimumab — and the Academy actually added a letter for us after I requested it!
DW: Would you recommend this tool to other dermatologists?
Dr. Porter: I would highly recommend it. It’s very easy to use; you just have to plug in the patient’s name and information, and it generates a complete letter for you which is formatted quite well. It is also a Word document, allowing for easy editing, if needed. The literature citations are very helpful, and I think one of the main reasons we have such a high approval rate for prior authorization appeals is because we use these letters.
Prior Authorization Tool
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