FORT WORTH, Texas — Treatment delays related to prior authorization and step therapy can be devasting to patients and demoralizing to nurses and physicians, but can sometimes be avoided through careful checking — and double checking — crucial information and forms, according to Laurie Heelon, a physician support specialist at the University of Rochester Division of Allergy, Immunology and Rheumatology.
“Every time there is a delay alert with prior authorization, it can eat up days or weeks for your patients,” Heelon told attendees at the Rheumatology Nurses Society Annual Conference. “To us, time and life keep moving, but to your patient it can freeze time when they cannot start their treatment, and it is absolutely crucial that they receive their treatment as quickly as possible. Often, they are dealing with a new diagnosis of a chronic illness, and then they have to deal with this wall of insurance and financial concerns.”
According to Heelon, it is also important for all health and clerical staff to understand step therapy, or the requirement set by insurance providers to try and fail certain other medications, before the physician-preferred treatment is approved for coverage.
Heelon added that nurses, who may already be familiar with the process, can help clerical staff understand step therapy and its ramifications for patients.
“It is important for clerical staff to be educated, hopefully by you and the providers, about these requirements that are in place regarding step therapy,” she said. “Those requirements are going to drive the bus on how quickly your patient will receive their medication.”
Just 1 hour prior to Heelon’s comments to the conference’s attendees, the American College of Rheumatology released a statement condemning a recent CMS decision to allow Medicare Advantage plans to adopt step therapy for Part B drugs.
According to Heelon, common reasons for prior authorization denials include the medication being off-formulary, off-label or otherwise experimental in their use. Step therapy requirements are also commonly the cause of denial, she said.
However, nurses and other health care providers can avoid delays related to prior authorization, Heelon said, by taking steps to ensure their forms and data are in order. Specifically, practices should take care to identify the correct insurance coverage and necessary forms for each patient.
In addition, practices must include all necessary data on their prior authorization form, including demographics, diagnosis code, dosage and frequency, and method of administration. Up-to-date chart notes must also be provided, she said.
“This all sounds basic but missing just one of the things on a prior authorization form is another delay alert,” Heelon said. “Just missing the full demographic, diagnosis code and other information — those are key distinctions we have to know when we submit the prior authorization. – by Jason Laday
Heelon L. Helping your patients get the drugs they need: Prior Authorizations. Presented at: Rheumatology Nurses Society Annual Conference; Aug. 8-11, 2018; Fort Worth, Texas.
Disclosure: Heelon reports no relevant financial disclosures.