Prior Authorization Roadblocks
Here is part 2 of 3 all about prior auths…be sure to read part 1 first!
You are standing at the pharmacy- innocently enough –just waiting patiently to pick up your medicine when the pharmacist comes over and says, “ok, well….your insurance will not pay for this drug right now because you need a prior authorization…”
At this point the pharmacist will most likely pause and see how you are going to react (i.e. upset but calm or upset and crazy).
Of course, because you have taken the time to read all about prior auths you will know exactly want needs to be done!
If you have a prior authorization required here are the steps…
Pharmacy gets P/A required rejection from insurance –at this point, you have a few options …
1. Pay the full price of the medication OR
2. Ask the doctor for a different medication. If you are going to do this, it is helpful to call the insurance company and ask, “I was prescribed drug A –is there any drug in the same class that is covered by my insurance plan?” This way, you can tell your doctor exactly which medications will be covered. (Often the pharmacy people can help you with this but if you ask for their help please be willing to give them hours to days for them to follow up) OR
3. Ask for a prior authorization. Which means, you ask the pharmacist or technician to fax your doctor with the information so that your doctor can contact the insurance company. I would also ask the pharmacist/tech for the phone number so you can have it available if you talk with your doctor.
If you decide to ask for a prior authorization, you should know that the pharmacy will fax the information over to the doctor. It is then in the doctor’s hands…they will need to call or fax over the information to the insurance company –the pharmacy is not really involved until the insurance company okays the prior auth.
Having said that, we will often try to help by pestering the doctor’s office with multiple calls and faxes to get the doctor’s office to actually do the prior authorization.
Once the information gets to the insurance company, they will review it and approve it or not (usually within 2-3 business days).
Seems easy enough, right?!….unfortunately, it often gets held up by…
Roadblocks to getting that prior authorization done already!
1. The pharmacy –does not fax the information to the doctor’s office –this can happen but it is not the norm because this is the easy part –all we do is send a fax and most pharmacies have a whole system where the fax is sent automatically to the doctor. (I am not just saying this because I am a pharmacist J)
2. The doctor’s office –ohh…there are many obstacles here…
a. The fax is tossed by whomever guards the fax machine.
b. The person we leave messages with does not understand what a prior auth is and does not pass on the correct message.
c. Your doctor’s office refuses to do prior auth because they think they are a waste of time (when you first go to see a doctor –ask her policy on prior auths).
d. The prior auth request is in the prior auth request bin and will sit there for quite a while –oh the frustration! Usually, doctor offices have one person that deals with prior auths -if and when- she has time (like I said earlier –no one likes prior authorizations!) This is the biggest issue because they usually get pushed to the end of the day…week…month…
e. The prior auth guru starts the process (i.e. gets forms faxed from insurance company) but never quite finishes it.
3. The insurance company –it usually takes 2-3 business days for the insurance company to yay or nay, once a completed prior auth is sent in from the doctor’s office. The main block here is that the insurance company looses it or deny it and just never contact the pharmacy or doctor’s office. (most likely, it is delayed here because the doctor’s office did not complete the p/a correctly).
4. Back to the pharmacy –the prior auth can be all ready to go but we just don’t know it because the insurance company and/or doctor’s office didn’t tell us to run it thru.
Okay, there you go –now you know all that can possibly stand in your way to getting your prior authorization done already. Read on to part 3 –What I can do to Speed the Prior Authorization Process Along!
Did I leave anything out? Go ahead and leave me a comment!
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