In a previous article: 5 frustrations with prior authorizations as nurse practitioners, I discussed the challenges NPs face. This article by The Nurse Practitioner Charting School will focus on tips to improve prior auth process as a nurse practitioner.
Prior authorization is the process of getting approval from a health insurance company for a prescribed medication, diagnostic test, or procedure. Prior authorizations cause many frustrations including delay in care, time spent by staff, and a lack of control as nurse practitioners.
I have personally experienced these challenges with getting prior auth approval. I have also realized that getting approval from health insurance companies is not going away and will actually get worse. I have worked on changing my mindset and implemented some improve prior auth processes.
Prior authorization process
Although health insurance companies require prior authorizations for prescriptions, diagnostic tests, and procedures, this article will specifically focus on ways to improve prior auth processes for medications. Here is the basic process for medication prior authorizations.
- The provider decides which prescription medication will best treat the patient’s condition.
- The provider may choose to research which med is on the health insurance’s plan preferred medication list (time consuming task for the nurse practitioner). Or the nurse practitioner may choose to send a prescription to the pharmacy.
- The pharmacy will run the medication through the patient’s insurance and if a prior auth needs to be completed, the pharmacy will notify the provider.
- The provider (or support staff) can then complete a prior authorization by discovering the appropriate form on the patient’s health insurance website. The provider/support staff may also go through a third party company such as CoverMyMeds or SureScripts to create a more streamlined process. These companies have access to insurance specific forms and often saves information such as the nurse practitioner’s practice location and prescribing information.
- The support staff or nurse practitioner will then complete the necessary prior authorization form. Information on the prior auth form includes:
- The patient contact and health insurance information.
- The provider’s practice location information.
- A list of the applicable ICD 10 codes (diagnoses) for why the medication is being prescribed.
- Any past medications that failed to treat the conditions and reasons why.
- Any medications the patient tried but did not tolerate and reasons why.
- Any applicable office notes or past medical records.
- The provider may also include specific information as to why this medication was being prescribed and why alternative treatment failed.
- This form is sent back to the patient’s insurance and a determination of coverage will be decided. The insurance company reviews the prior auth form and may exclude for:
- Certain criteria (such as age)
- If the medication is not on the preferred drug list
- If the patient does not have the specific diagnoses
- Services not covered by current insurance plan (i.e. some companies don’t cover for weight loss treatment/medications)
- If the medication is not medically necessary
- The health insurance company will then send the decision to the provider, the pharmacy (make sure to add pharmacy contact information), and the patient.
- If the prior authorization is denied. The support staff/nurse practitioner may choose to complete an appeal, providing more information and reasons why the patient should take the medication.
- Again, the health insurance company will give their decision to the provider, pharmacy, and patient.
This is the basic process of completing a pharmacological prior authorization. Each practice setting may have their own process such as who is completing the appropriate forms. Each health insurance company has their own prior auth form and information that is requested. But all healthcare facilities should improve prior auth processes so they can provide better patient care AND save time!
Improve prior auth process
Below are 11 tips to improve prior auth process as a nurse practitioner!
Ensure accurate information.
Be careful to ensure accurate information when completing a prior authorization. For example make sure you have correctly input the patient’s birthdate or health insurance policy number, being careful to avoid typos.
Also ensure you have the correct, up-to-date insurance card on file. One time when I was completing a prior auth, I assumed the insurance policy was valid in the state the patient lived in, however, the patient’s employer was based in a different state so the health insurance was private insurance of a different state. I couldn’t figure out why the prior auth came back stating the patient no longer had healthcare coverage.
Another example was when I completed a prior authorization with the patient’s secondary insurance instead of the primary insurance. I was frustrated when I had to complete the form all over again with the correct insurance. These are small things by which we can improve prior auth processes.
Special criteria for medication.
Some medications have specific criteria such as age that will automatically not qualify the patient. If a patient is 17 years old but the medication is only indicated for patients 18 years of age the medication request will automatically be denied.
Same is true about the specialty of the provider. For example, a nurse practitioner who works in primary care will not be able to prescribe chemotherapy. And some of the new migraine treatment medications can only be prescribed by a neurologist. Nurse practitioners who are aware of these regulations will know to send a referral instead of filling out a prior auth.
Ensure information is complete.
Nurse practitioners can improve prior auth processes by ensuring information is complete. Oftentimes the health insurance companies want to know what previous medications were prescribed and if there was an intolerance or failure of treatment.
Many health insurance companies will approve a prior authorization if there is proof that the preferred medications did not help treat the condition. Also ensuring that all necessary information on the prior auth form is completed so it does not delay approval if more information is requested.
Know dosing limits.
I once completed a prior authorization that was denied because of the incorrect monthly supply of the medication. The medication was Ubrelvy, taken for acute onset of migraine. I had sent for 30 tablets in a 30 day supply. The prescription was denied because the insurance company would only allow 15 tablets to be dispensed monthly.
This makes sense since the mediation is to be taken only for acute migraine. It may be difficult to know what number of tablets is approved for each different medication, but I wish I would have known that before spending time completing a prior authorization. Becoming aware of certain dosing limitations such as this example improve prior auth processes and avoid completing an appeal.
Check the preferred drug list.
Most health insurance companies have their own list of preferred medications. Oftentimes there are different levels or tiers meaning some medications are covered better than others. Many health insurance companies have this preferred drug list on their website. The nurse practitioner or support staff may search this list and choose a medication that is under tier 1 or the best covered medication for the drug class.
While this process can avoid a prior authorization, there are a few downfalls. It can take a lot of time for the provider to search the drug list and figure out what is most preferred. Sometimes the drug lists are not up-to-date (especially after changes made after January 1st).
It may be a waste of time to investigate the preferred medication because the health insurance company may have changed the favored drug. Sometimes a prior authorization still needs to be completed even after reviewing the preferred drug list. Being aware of the health insurance’s preferred drug list will help improve prior auth processes as nurse practitioners.
I have to constantly remind myself that even though it doesn’t seem like it from the outside, health insurance companies truly want to help the patient. They have strict guidelines to ensure the treatment is medically appropriate and that safe prescribing is occurring. The insurance company tries to keep costs down for the patient by avoiding any unnecessary tests or procedures.
When I talk on the phone with a health insurance company representative, I have to avoid taking my frustrations out on the person. It is not their fault they have to enforce the guidelines. I have to take a step back and reflect on why I am overwhelmed.
I am usually frustrated because I am spending a lot of time completing the prior authorization and I feel like I lack control in caring for the patient. I have to remind myself these are my own emotions and insecurities and should not take them out on someone else.
Complete an appeal.
If the prior authorization was not approved, an appeal can be completed by the nurse practitioner or support staff. The appeal provides additional information and reasoning for why the medication was prescribed. I often become frustrated because an appeal takes additional time and energy to complete. But sometimes an appeal can get approval of the medication.
It is best to use the tips in this article to ensure you have accurate/complete information and improve prior auth processes. This will help avoid a denial from insurance and need to complete an appeal. But sometimes denials occur and an appeal needs to be completed.
Assist support staff.
If you are a nurse practitioner delegating prior authorizations to support staff, there are a few tips to help set them up for success.
- First off, choose a prior authorization specialist. It may be beneficial to assign one staff member to complete all the pre approvals. This way they can become the experts and know what information the health insurance company needs to approve medications.
- Second, be patient with support staff and the prior authorization process. As previously discussed, getting pre approval can take time and energy to complete.
- Third, be very specific with any past prescriptions or medical treatment that was not tolerated. Explain which medications failed and why. It helps the support staff know exactly what to put on the prior auth form to gain approval and avoid having to complete an appeal.
- Fourth, schedule a specific time, (i.e. Wednesday morning at 8:00am) to review any approved, pending, or denied prior authorizations. Any patient specific information can be discussed at this time. Scheduling a specific time allows the nurse practitioner to be updated with any changes to prior auths.
Educating and encouraging support staff can help improve prior auth processes in any practice setting.
Update the patient.
Keeping the patient informed and aware of the prior auth process is important when providing quality patient care. Patients may not even realize certain medications need to be pre approved through their health insurance. I always warn patients that we may have to complete a prior authorization for the medication. I also explain that it will take several days to process the information.
If the request is denied, I try to update patients and explain I will do an appeal or help find alternative options. Patients are much happier and appreciative when I update them on the prior authorization process.
Nurse practitioner practice tip: I also try to keep patients informed when waiting for test rests or explaining a diagnosis. One of the top reasons patients sue providers is because they were rude or did not explain the information properly. Happy and informed patients are less likely to file a medical malpractice suit, so I strive to do this with all my patients.
For more information on ways to prevent a negative outcome of a malpractice case, check out Legal Issues with Charting Course.
Utilize a third party company.
The provider/support staff may choose to utilize a third party company such as CoverMyMeds or SureScripts. These companies have access to insurance specific forms so nurse practitioners do not have to search each health insurance website individually. These platforms also save information such as the nurse practitioner’s practice location and prescribing information.
These benefits decrease time spent and improve prior auth processes. It is also helpful all the information is in one place, so the nurse practitioner can log on and follow-up on any previous prior authorizations.
Continue to improve prior auth processes.
I have definitely gained knowledge of the prior authorization process. I have a better idea of what the insurance companies need in order to approve a medication or test. For example, I know I need to get an X-ray of a shoulder before I even think about ordering an MRI. Or I need to document the list of medications that did not work for the patient so there is written proof.
I have definitely put more focus on ways to improve the prior authorization process. As a nurse practitioner, it is vital (pun intended) to learn and grow as we practice. I am no expert but I have definitely gotten better in my clinical practice. And I know I will continuously grown and learn!
Bonus tip: Utilizing a Virtual Medical Office Support
You may have heard of a virtual scribe to help get chart notes completed. But have you ever heard of a virtual medical office support (VMOS)?
A VMOS is a highly trained individual that connects virtually and can complete multiple different tasks. For example, a virtual medical office support can complete prior auths for you! This will save so much time and improve prior auth process!
The nice thing about virtual scribes and virtual medical office support is that the healthcare institution doesn’t have to hire on another employee. This is a tremendous benefit in this current era of staffing shortages. There are virtual scribe companies, such as ScribeEMR, that provide these virtual workers for you!
For more information about virtual scribes and virtual medical office support, schedule a consultation call with ScribeEMR.
More time management tips for nurse practitioners
These are tips to help nurse practitioners ease the challenges of completing prior authorizations. Getting pre-approval from a health insurance company for medications, tests, or procedures is not going to get any better in the next few years (it will likely get worse!). So we need to improve prior auth processes as nurse practitioners!
If you are a nurse practitioner having to stay late at the office or bring charts home, you have come to the right place! The Nurse Practitioner Charting School specializes in helping nurse practitioners improve their charting. And on of the ways is through The Time Management and Charting Tips Course!
Also check out The NP Charting School’s Comprehensive List of Smart Phrases– access to over 125 smart/dot phrases ready to implement into your electronic medical record!
And if you need more help with charting, check out The NP Charting School’s other online courses/resources!
Basics of Billing and Coding Course : Feel confident choosing the correct Evaluation and Management CPT® code for an outpatient, inpatient/obs, ER, and nursing facility patient visits, so you can avoid over coding (and under coding!) ensuring you receive proper insurance reimbursement!
Legal Issues with Charting Course : Learn how to prevent a malpractice suit and put your mind at ease regarding legal issues of charting.
Charting as a Nurse Practitioner Student Course: Going through nurse practitioner school is incredibly overwhelming. Don’t stress about the charting.