Prior Authorization Workflow

For the story below, imagine a small dermatology practice, with three dermatologists, two nurse practitioners (NPs), and two office administrators. The dermatologists see 30-40 patients a day for many different procedures, ranging from the cosmetic to non-cosmetic. Prior authorization is needed for certain procedures and medications.

Note: This is an example of the steps it could take to do a prior authorization. Workflow will vary by dermatology practice and insurance company.

Step 1: Set initial appointment

1. The dermatologist informs the office administrator of the prescription and that Dupixent is deemed essential for the patient.

2. The administrator assists the office staff to prepare materials for the insurer that justify medical necessity. Materials are transmitted by fax, electronic prior authorization (ePA), or other workflows.

3. The insurer receives the prior authorization request for Dupixent and determines next steps on that same day, June 1.

Tips

• Utilize patient portals that assist with HIPAA-secure messaging from physician staff to patients. Check out the Academy’s page on Patient Portals and understand how they can improve efficiency.

Step 2: Create prior authorization

1. The dermatologist informs the office administrator of the prescription and that Dupixent is deemed essential for the patient.

2. The administrator assists the office staff to prepare materials for the insurer that justify medical necessity. Materials are transmitted by fax, electronic prior authorization (ePA), or other workflows.

3. The insurer receives the prior authorization request for Dupixent and determines next steps on that same day, June 1.

4. The patient waits for updates from the insurer and dermatologist office.

Challenges

• Each insurer has a different process for submitting prior authorization. Sometimes, a prior authorization needs to be sent to the pharmacy through fax or EHR before the insurer is involved.

• In some academic practices, dermatologists take more than 25 insurance plans, and the rules frequently change. In some instances, a treatment is approved promptly, but in other cases, that same treatment is denied.

Tips

• Dermatologists should use ePA software programs* whenever possible. These programs have prior authorization built into the platform or integrate with the EHR to reduce denials.

• Make sure your practice is familiar with the steps involved before submitting a prior authorization, including whether it goes to the pharmacy or insurer.

• Use pre-populated forms that match the insurer’s forms.

Step 3: Response plan

1. On June 12, the insurer communicates the update with the office administrator. Dupixent was denied, but the practice can appeal. On the same day, the insurer informs the patient through a HIPAA-compliant portal of the denial.

2. Non-physician clinician. The non-physician clinician hears from the insurer and informs the dermatologist, then prepares materials for an appeal and submits it on June 13. They also communicate next steps to the patient through the patient portal.

Challenges

• If the insurer needs more information from the dermatologist, this typically delays approval, which could impact the patient’s health.

• Additional phone calls between administrator, insurer, specialty pharmacy, and patient usually occur, increasing burden.

• Patients and providers often do not hear updates from insurers in a timely manner, or there is no communication at all.

• Prior authorization could take up to 30 days for a determination, depending on what materials the practice provides.

Tips

• Frequently follow up with all parties to prevent unnecessary delays.

• Document each part of the process and keep it in a file.

• Denials are an opportunity to use the AAD’s prior authorization appeal tool. The tool generates appeal letters for commonly denied dermatological drugs, such as Dupixent.

Step 4: Prior authorization approval

1. On June 24, the insurer approves the prior authorization denial appeal and communicates with the dermatology practice. The insurer also sends an email to the patient stating the medication is approved.

2. On June 24, the non-physician clinician communicates the approval to the dermatologist and sends the patient a message through the patient portal.

3. The dermatologist calls the patient with reminders about the treatment process, which was previously discussed in the office. The patient is instructed to return in three months to discuss their progress.

4. The patient begins medication for atopic dermatitis.

Challenges

• Medication costs can be high, even with insurance coverage. If the cost is a burden to the patient, they may stop taking their medication.

• Sometimes, the insurer only communicates with the patient on the status of the prior authorization. Unless the patient communicates these updates to the practice, the dermatologist suffers from radio silence.

Tips

• Encourage patients to discuss cost concerns. Consider offering ways to decrease their drug costs and search other drug prices in your area.

• After a successful prior authorization, the administrator should document the steps taken and apply lessons learned. Success with one insurer can provide a template for success with others.

Related Academy resources