Are medication prior auths impacting your day? Feedback please

[5150rn2]

0I am in the process of starting a full service prior auth writing service.

In the course of practice I have dealt with writing prior authorizations, mainly for medication. I know how they impact daily work flow and that sometimes because of the block of time required they often are set aside until that block of time appears. I have also begun to see a trend of simply switching to a less effective formulary option to save time.

My motivation is improving patient outcomes by helping get them the meds they would benefit most from. So many patients don't even know this option exists.

So my marketing proposal is to save prescribers/ prescriber staff valuable time that could be better used seeing patients. The second point is saving them money. Using an independent service as needed eliminates the need to increase staff to accommodate which includes the additional cost of paying benefits, paying social security, workers comp etc and training staff.. the provider can actually use the time to see more patients, increase billable hours ( Time spent writing PA's are not billable) vs using a service when you need them.

By full service I mean, doing everything. Office contacts me, provides me name of patient, medication, pharmacy and payor. I then access record, research history and if necessary supplement justification with additional info found online, this is then presented to payor. Follow up as needed, provide additional info/ justification as needed. And when it's all done, notify provider. Allow me if they choose to adjust order if all that needs to be changed is dispense #or strength of medication as long as the order essentially is unchanged. Additionally if provider wants, contacting pharmacy and patient.

So I could save them time and money and help them improve patient outcomes.

i am right now HIPAA compliant, email, fax. Computer is secure, assessed and changes made for security of info by a cyber consultant.. so now... I am trying to figure out the best way to obtain clients. Obviously large clinics, healthcare systems are taken care of in house. So independent practices, smaller clinics.

I think my hesitation right now is everything is theoretical.. I need a couple/few beta clients. Hands on see what remotely accessing records will entail.. once I get that,I am good to go.

i am a CA. Licensed RN with over 20 years of experience, with very good research, writing and verbal skills.. and my driving goal is being an advocate for patients.

After googling I have found similar services but none that are start to finish or independent. So I have to create from scratch.

i would really appreciate any thoughts or feedback regarding this venture.

Website should be live in about a week, advertising sources are being considered..Name of Service = PRN Rx Solutions.

Am I crazy off base? Providers have said they would love such an option, but they aren't the decision makers.. I believe there's potential and I don't want to blow it. But I am at the proverbial fish or cut bait, step up to the plate, jump off the high board...

thanks in advance...

[MunoRN, RN]

I'm not sure how that would benefit a physicians office since insurers already employ nurses who deal with prior authorizations. If a physician prescribes something that is not on a plan's formulary then staff employed by the insurer offer alternatives, so I'm not sure how dealing with prior authorizations outside of the insurers would in any way help a private practice physician.

[5150rn2]

Actually, that's not quite right. The insurer WILLprovide formulary alternatives ( call center folks from a pre-determined protocol. HOWEVER.. when for a dozen different reasons that formulary substitute won't be appropriate or best choice, it is the PRESCRIBER who essentially provides justification for getting the original choice covered. The prior auth is the pts info, meds trialed, what you want and why.

The insurance company says no, provider says reconsider, here's why. It's that service I will provide. It is becoming an unfortunate trend that for whatever reason ( usually time) the providers office defaults to insurance company's choice whether or not it is best for the patient.

You won't see prior authorizations in a hospital setting. These are generated at the outpatient ND office/clinic level .. if the provider doesn't just default.

[Wuzzie]

How would you get the patient's demographic and clinical information that is needed for PAs.

[5150rn2]

Ideally my plan/intent is to be able to access EHR's remotely. I have gone through great lengths to make sure I am absolutely HIPAA compliant and my computer, fax, email is secure. Because of the services I am doing business with to accomplish this meet HIPAA standards, I will have HIPAA partner agreements from them which in turn allows me to provide agreements to potential clients. I had a cyber security/HOPAA consultant go through everything. Because to make this actually work, I have to be able to access remotely, which means I HAVE to be safe and compliant. Honestly it is conceivably possible that I am more secure than some provider offices.. But I have to be..

If someone is still using paper record I will be very limited as they will have to be local to me .

Like I have stated, ideally I need 2-3 beta clients so I can make sure there are no kinks. I have done PA's for so long the only question is being able to access records. After that I am good to go. And most records have the capability to be accessed remotely.

So if you're in CA and know of some prescribers who would like to have PA's done for free initially and then permanently discounted for the duration of the business relationship..let me know, I would love the opportunity to present to them....

[MunoRN, RN]

I'm not sure how that would mean less for the physician. Without your proposed service, they would have to document the basis for covering an non-formulary medication and communicate that to the insurance company. With your proposed service they would still have to document the basis for covering a non-formulary medication and then communicate that to you, so it seems like the same process for the physician except with you as the middle man.

[Neats, BSN]

This should be Titled Insurance 101

While at a major insurance company I was the Pharmacy RN...We do not give advice in what can or cannot be provided. Any prior authorization requested (this includes dose change) needs supporting documentation. We follow the FDA guidelines, and evidenced based industry standards....as long as you submit the supporting documentation I am more than inclined to approve the request with this documentation, because if someone comes after me looking at the case they can review the supporting documentation. I see a lot more provider offices outsource their "administration" requests for routine prior authorizations, specialty requests like oncology the office RN is the one who usually requests the services/medication., most insurance nurses have good working relations with these nurses.

I can see you working in this capacity with patients who can afford your services and maybe small businesses of less than 100 people. These are the people who really need the services of how to navigate the healthcare system. Just a side note: There is so much transparency out there now with insurance companies that all one needs to do is go online to your insurance company and find the formulary, find the Medical Policy and just follow what their criteria is...send it in and if it meets it will be approved. Please Note: there are also FDA approved medication that have insurance non-coverage...why because although it is FDA the trials also show that the medication has not been established for efficacy ...that medication should continue with trials and the drug company should pay for that not the insurance company.

The most issues I have is when an office staff person just sends in any documentation like from 5 years ago...they should really know that if you are asking for Remicade the notes should reflect anything currently related to the reason why you want to use it not just send in the initial diagnosis of Crohns from 5 years ago. I want to know how you are doing on this medication now. Like Botox for migraines, I want to know migraines, how many, how long do they last, what medication worked or not worked... not just headaches that will not go away. Requests/documentation submitted should again reflect the Medical Policy/criteria and the current patient status.

Lastly I get yelled at, told I was denying life saving medical care. I do not deny, any thing that does not meet criteria is sent to a medical director for review... and please know anytime there is an denial the insurance company does not keep that monies, the company you get your insurance from or your significant other... the company you work for is saving that monies. Just a little unknown fact. The insurance company job is to administer your benefits that your company picked for you and decided the criteria.