Prior Authorization

By Initiating PAs, Providers Can Give Pharmacists Time with Patients

Patients see pharmacists twice as frequently as they see physicians, yet the burden of administrative tasks like prior authorization (PA) requests can hinder those face-to-face interactions. Providers can help by initiating PA requests at the point of prescribing, thus freeing pharmacists’ time to care for patients — as they were trained to do.

Miranda Delatore, MSN, RN, NEA-BC
Miranda Delatore, MSN, RN, NEA-BCVP of Network Operations
September 28th, 2022
By Initiating PAs, Providers Can Give Pharmacists Time with Patients
Providers can help by initiating PA requests at the point of prescribing, thus freeing pharmacists’ time to care for patients — as they were trained to do. *Photo credit: Katie Chandler*

When’s the last time a patient walked into their doctor’s office without an appointment to ask a question? If they’re like the majority of Americans, the answer is probably never. According to one report,Infographic: Average Wait Times to See a Doctor, relyMD, Mar. 22, 2018 60% of patients wait two weeks for an appointment with their primary care provider and only 10% see their regular doctor the same day they request care.

Conversely, it’s common for people to enter a pharmacy and approach the white-coated professional behind the counter with a question about their medication or condition. One studyPharmacists as accessible health care providers: quantifying the opportunity, National Library of Medicine, Mar. 2, 2022 estimates patients visit their community pharmacies almost twice as often as their physicians — a trend further advanced by the COVID-19 pandemic and the rise of telehealth.

As it turns out, that’s a good thing for pharmacists, since they enjoy those patient-facing engagements. According to the 2022 Medication Access Report, when asked about their most satisfying job components, 80% of surveyed pharmacists listed “counseling patients on their medications,” and 72% listed “counseling patients on their condition.” However, their daily to-dos go above and beyond those fulfilling activities and have grown to include tasks like vaccine administration, eligibility benefits verification and drug utilization reviews.

Given that list, it’s no wonder pharmacists are facing burnout. In fact, 74% of surveyed pharmacists said they don’t have enough time to safely perform patient care and clinical duties,American Pharmacists Association, National State-Based Pharmacy Workplace Survey, Dec. 2021 and in another survey 73% listed administrative tasks2022 Medication Access Data Guide, CoverMyMeds, 2022 such as prior authorization (PA) as a time-consuming culprit.

But there’s good news: 25% of providers are starting to initiate PA requests prospectively, at the point of prescribing, compared to 17% in 2020 and just 7% in 2019.CoverMyMeds Provider Surveys, 2019, 2020, 2021, CoverMyMeds data on file That change positively impacts pharmacists’ experience on the job and helps patients, since they access their medications 13.2 days sooner on average when PA requests are started at the provider’s office.Electronic Prior Authorization, Status of ePA, CoverMyMeds Medication Access Report

Based on my experience interacting with retrospective PAs as a pharmacist, it’s not efficient, and it’s not a good experience for anyone.

Adam Harbert
Pharm.D., clinical pharmacist at CoverMyMeds

According to Adam Harbert, Pharm.D., clinical pharmacist at CoverMyMeds, providers have been encouraged to initiate PA requests at the point of prescribing for several years. But the recent uptick can be attributed to three different causes — the first two relate to notable industry shifts.

  1. On Dec. 29, 2020, the Centers for Medicare & Medicaid Services (CMS)CMS names an e-prescribing standard to reduce provider burden and expedite patient access to needed medications, Centers for Medicare & Medicaid Services, Dec. 29, 2020 announced a rule requiring Part D prescription drug plans to support a new electronic prior authorization (ePA) standard. This rule allows providers to see whether a drug is subject to PA while they’re prescribing it. CMS began enforcing the new rule on Jan. 1, 2022.
  2. On Jan. 15, 2021, CMS announced another rule requiring Part D plans to offer a real-time benefit comparison tool. This rule allows enrollees to obtain information about lower-cost alternative therapies under their prescription drug benefit plan.Changes to Medicare Advantage and Part D Will Provide Better Coverage, More Access and Improved Transparency for Medicare Beneficiaries, Centers for Medicare & Medicaid Services, Jan. 15, 2021 With a real-time benefit comparison tool, providers can see if a PA is required for specific prescription drugs.
  3. According to the American Medical Association,Prior Authorization Physician Survey Update: Measuring progress in improving prior authorization, American Medical Association, 2021 Update 84% of physicians report the number of PAs required for prescription medications has increased over the last five years. On average, almost 1 in 5 prescriptions require PA. As providers become accustomed to working PAs, they may be more likely to do so prospectively, at the point of prescribing, versus retrospectively, after a pharmacist indicates one’s needed after a claim has been rejected.

“Based on my experience interacting with retrospective PAs as a pharmacist, it’s not efficient, and it’s not a good experience for anyone,” Adam said. “If patients go to the pharmacy and can’t pick up their prescription, they’re not happy and their providers hear about it. The more that has happened, the more providers have realized there’s a better way.”

Why the difference between retrospective and prospective PA requests matters

To get a better understanding of the two ways to initiate PA requests, here’s a breakdown of each method’s steps:

The retrospective PA process:

  1. Provider prescribes prescription (Rx) drug, sends Rx to pharmacy for fulfillment
  2. Patient attempts to pick up Rx; pharmacy technician receives rejection notification from plan
  3. Pharmacy technician initiates the PA request and sends it to the provider to complete and submit
  4. Plan receives and adjudicates PA request; patient is approved to pick up Rx

Some plans, such as Medicare, also have a tolling requirement. So, if a pharmacy initiates a PA request, the provider has 10 business days to respond. Otherwise, the PA request gets automatically denied due to lack of response and must go through an appeals process — thus increasing delays.

The prospective PA process:

  1. Provider sees PA is required; initiates, completes and submits PA to plan, then Rx to pharmacy
  2. Patient arrives at pharmacy to pick up Rx, pharmacist has fulfilled prescription upon determination
  3. Pharmacist dispenses prescription drug; patient starts on therapy as planned

As you can see, the retrospective process requires an extra step — and extra time. With providers initiating PAs prospectively at the point of prescribing, patients can receive their medicine faster and pharmacists can focus on other things.

Three benefits pharmacists experience from a decrease in PA burden

According to Adam, pharmacists experience three major benefits when their PA burden decreases:

Benefit No. 1: Reduce manual administrative work

The PA process isn't straightforward, and it involves communication among payers, pharmacy benefit managers, pharmacies and providers. To successfully process PAs, pharmacists must track down information like diagnosis codes, insurance benefits and compliance regulations. By eliminating the administrative work caused by initiating PA requests at the pharmacy counter, pharmacists would have more time to spend educating patients on their medications.

Benefit No. 2: Prevent medication errors

The FDA receives more than 100,000 reports of medication errors every year, and one of the main causes is prescription medications being prepared or dispensed improperly.Medication Errors Statistics 2022, SingleCare, Jan. 20, 2022 We know pharmacists have a lot on their plates. If they have to toggle between the phone, fax machine and computer while also dispensing medications, the likelihood of errors occurring increases — errors that impact patient lives. Indeed, 7,000 to 9,000 people die due to medication errors annually in the United States, and the total cost of looking after patients with medication-associated errors exceeds $40 billion each year — with over 7 million patients affected.Medication Dispensing Errors And Prevention, National Library of Medicine, July 3, 2022

Benefit No. 3: Complete patient counseling

Pharmacies — like any business — are dependent on customer satisfaction, and reviews matter. These days, it’s not uncommon for patients to be asked a question like, “Did your pharmacist offer you counseling today?” via an iPad survey upon checkout. If the patient has a bad experience because the pharmacy’s staff members were too busy completing administrative tasks, that may reflect badly on the pharmacy’s reviews and their financial performance.

I have no doubt that, eventually, pharmacists will be able to make therapeutic interchanges on their own for patients.

Adam Harbert
Pharm.D., clinical pharmacist at CoverMyMeds

What’s next for pharmacy?

Pharmacists are playing a bigger role in the patient journey than ever before,Pharmacists' Role to Expand Amid Pandemic and Provider Shortages, Columbia Mailman School of Public Health, Jan. 11, 2022 and nearly 80% of patients see pharmacists as a central component of their healthcare team. According to Adam, next on the agenda is the national recognition of pharmacists as providers. It’s likely, he said, that they’ll be given the same status physician assistants and nurse practitioners have already obtained.

“I have no doubt that, eventually, pharmacists will be able to make therapeutic interchanges on their own for patients,” Adam said. “We are the drug experts — we go through six years of education and training, and we’re easily the most accessible healthcare professional. Patients already see us as providers, so that formal recognition is the obvious next step.”

Beyond prospective PAs, other innovations can help pharmacists streamline their workflows. For example, automated central fill/mail order systems can help process prescriptions on behalf of pharmacists, leading to fewer errors and audits. Additionally, in-workflow electronic prior authorization (ePA) solutions that automatically prompt pharmacists to initiate PA requests if they’re needed are invaluable.

As these technologies become more widespread, so too can the influence pharmacists have on patient lives.

To learn more about the expanding role of pharmacists, download the 2022 Medication Access Report.

Miranda Delatore, MSN, RN, NEA-BC
Miranda Delatore, MSN, RN, NEA-BCVP of Network Operations

Miranda serves as vice president of network operations and brings a clinical voice to innovation.

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