Of all the scary terms in the retail pharmacy world (not to mention among doctors and their staff), surely the words "prior authorization" are the worst.
They are the seven syllables of death. They are the Freddy Kruger and Chucky and Cujo of our prescription-filling screen show all rolled up into one. They are the proverbial dead fly in the apothecary's ointment (see Ecclesiastes 10:1). We hate them.
For those who are not acquainted with the community pharmacy business, the issues related to prior authorization requirements may be unknown. What we are talking about is the situation where a prescription is ordered and, when trying to fill it, the patient's insurance denies the claim indicating that "prior authorization" is required.
At this moment, the pharmacy has some additional work to do.
First, the pharmacy must inform the bewildered patient what this means. This is no easy job. The patient sometimes reacts with understandable frustration. A doctor wrote the prescription, what more authorization could they need?
The pharmacist or pharmacy tech (or whomever draws the short straw) has to tell the patient that this process may take anywhere from a few hours to a few days (or longer). The patient is then left to wait, or return to the doctor for an alternative prescription or maybe some samples to hold them over for a few days.
Second, having attempted to explain the situation to the patient, the pharmacy will often then contact the prescriber. The mechanism for contacting the prescriber is by no means consistent across the industry. For new pharmacies or slower stores, it might mean picking up the phone and making a call. For busier pharmacies it typically means a fax is going to be sent to the doctor's office.
Finally, the prescription with the dreaded prior authorization rejection is left in "rejection" limbo. What do you do with the prescription in the meantime? Some software systems are robust enough to allow holding those specific prescriptions in a queue that can be set to try and fill the prescription again in 2-3 days.
But if it still rejects, then what? Maybe the pharmacy will make some more phone calls. Maybe the patient will call, frustrated and wondering what is going on with his/her prescription. Or maybe the prescription will just get put back "on hold" and left to die a slow death, never getting filled or taken.
The whole process is a mess.
Prior authorization rejections interrupt the normal pharmacy workflow and create distractions that almost certainly lead to lost efficiency at least and prescription errors at worst. Patients are frustrated, as most have no idea how the process is supposed to work.
The result is that a statistically high number of these prescriptions will be "abandoned" (that is, never picked up and never replaced). Providers spend an enormous number of hours just dealing with prior authorization requirements, increasing the cost of providing such care to patients.
Prior authorizations are a necessary evil of sorts. Without these roadblocks, healthcare costs would undoubtedly go up, at least the costs of prescription medications. We can't all be put on the latest and greatest drug for our particular condition, especially when it is likely that an equally effective generic is available.
Yet it seems to me that the health plan that stops the prescription from getting filled has a significant responsibility to ensure the patient is cared for. Shouldn't they reach out to the patient and doctor to coordinate an effective treatment option or to communicate their criteria? But insurance companies typically do nothing in this process at all.
Of course, they say every problem is an opportunity in disguise. Many pharmacists and pharmacies have taken this frustration as an opportunity to demonstrate added levels of patient care.
Nevertheless, the whole thing is still something of a nightmare. Someone wake me up. I need to get back to work, and I think I hear Cujo growling.
