Background/Purpose:   The vast majority of medications prescribed to treat rheumatologic conditions now require insurance prior authorization (PA) before the medication will be paid for by insurance and available to a patient.  We found increasing clinical staff and physician time being devoted to obtaining PA’s.  We initiated a quality improvement project with the goal of decreasing the time between PA initiation and completion and the effort dedicated by clinical staff to completing each PA.  

Methods: In our university-based rheumatology practice, we evaluated 10 PA’s from 4 time periods to assess the change in the total days between initiation and completion of each PA.  We also assessed the number of entries in the electronic medical record (EMR) about the PA, whether it was approved or denied, and whether an appeal was made.  Inclusion criteria for evaluated PA’s included: DMARD or biologic medication, on-label use, and sufficient information in the EMR to determine PA status.  We reviewed 4 time periods: 1. Baseline; 2. Covermymeds® when multiple clinic employees were assigned to submit PA’s electronically using covermymeds®, provided a PA form, and in a percentage of patients provided a real time approval/denial; 3. Insurance specialist when we were no longer allowed to use covermymeds®, an insurance specialist from our clinic would obtain and complete the correct PA form from the insurance company and complete needed follow-up; 4. Phone line when a dedicated phone line and full-time clinical staff member responded to both patients and insurance companies; in addition, a patient education hand-out and educational tools were developed for both clinical staff and providers.

Results: Over a 10 month period, 9,943 patient visits in the university rheumatology clinic resulting in 2,835 prescriptions requiring a PA.  Approximately 29% of arrived patient visits in our clinic require a PA during this time period.  The duration between PA initiation and completion as well as the number of EMR notes required per PA varied over the time periods with improvements seen with the use of covermymeds® and a dedicated phone line and staff member.  The approval rate for the on-label use prescriptions was high and few appeals were needed. 

Conclusion:   Our findings suggest that submitting PA’s electronically, minimizing the number of staff members involved in the PA process, education related to the PA process, and having a dedicated telephone line, have had the biggest impact on improving our success. This level of support requires a full-time clinical staff member, increasing our personnel cost. We suspect that a systematic change on both a state and notional level within the healthcare system will be required to force change. 

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/improving-the-medication-prior-authorization-process-in-a-university-based-rheumatology-practice/