Critical Prior Authorization Challenges in Specialty Pharmacy Billing

Prior authorization plays a critical role in your overall specialty pharmacy billing process. Obtaining prior authorization is crucial for several reasons such as optimized reimbursements, avoiding claim denials and proper patient care. As specialty pharmacy drug prices continue to rise, insurance companies require you to obtain prior authorization for certain specialty pharmacy drugs. Although, the primary objective of prior authorization is to manage specialty pharmacy costs, they can pose the following challenges in your specialty pharmacy billing process-

Critical challenges associated with specialty pharmacy PA

significant administrative time:

According to a survey conducted by the American Medical Association (AMA), specialty pharmacies spend an average of 13 hours every week on managing PA. With constant labor shortage, this time is often considered as wasted, especially, when direct revenue-collection tasks are concerned.

Cost to your specialty pharmacy:

Most specialty pharmacies need to hire staff just to handle PA-related tasks like filling out forms and conducting phone calls with insurance companies. You need to bear all these costs by yourself.

Delayed care:

Insurance companies often take days or weeks to process your PA requests, which may delay patient care. This delay can cause a worsening of the patient's health condition as the patient remains untreated during the time gap.

Lack of standardized approach:

Depending on the level of specialty pharmacy drugs, you must navigate different requirements and regulations set by various payers. The lack of standardized procedures often causes confusion and errors, resulting in further delays and potential harm to patients.

Fortunately, you can navigate the prior authorization process successfully by following some effective tips mentioned below-

Tips to improve your specialty pharmacy PA process:

Understand the process clearly:

Make sure you familiarize yourself with a patient's insurance company's prior authorization guidelines and requirements. Fill in necessary forms accurately and make sure the documentation is proper.

Effective communication:

Communicate with patients clearly about the prior authorization process, including any potential delays or requirements.

Progress monitoring:

Monitor the entire process of a prior authorization. Do timely follow up to ensure timely PA approval from an insurance company.

Stay up to date:

Keep up with changes to prior authorization requirements and regulations and adjust your processes, as necessary.

To avoid all the potential pitfalls in specialty pharmacy billing and PA processes, most specialty pharmacies outsource their PA processes to professional specialty pharmacy billing companies.

If you are also searching for a perfect company to manage your PA process, Sunknowledge can be the perfect destination. Sunknowledge's professionals manage the entire authorization process, including initiation, prompt submissions, follow-ups, and other authorization tasks for your specialty pharmacy and ensure timely approvals from insurance companies. To know more about their services, connect with one of their experts on a non-commitment call today.