Because specialty pharmacies often deal with new drugs that are subject to more FDA regulation and compliance oversight, they must take special care when completing prior authorizations. Often, these new drugs haven’t even made the payer’s formulary lists, meaning that prior authorizations are definitely required. Furthermore, payers demand robust, accurate documentation before approving a new drug prior authorization. Approval can require many lengthy phone calls between the pharmacy and the payer, a process that takes hours.
Specialty Pharmacy Struggles Amid Healthcare Staffing Shortage
This was the case for two specialty pharmacies under the umbrella of a large nationwide pharmacy network. Unable to hire and retain staff amidst an unprecedented healthcare staffing shortage, they struggled to complete their prior authorization follow-ups with payers.
One specialty pharmacy works with oncologists, hospitals and health systems, manufacturers, and health plans to deliver a high level of quality care to cancer patients. It dispenses through its network of URAC-, ACHC-, and NABP digital-accredited oncology pharmacies. The other specialty pharmacy provides urology-specific care management programs, dispensing urologic medications Erleada® (apalutamide), Lupron Depot® (leuprorelin), Nubeqa® (darolutamide) and more. Their parent company is a national leader in pharmacy services, serving more than 3,100 long-term care, specialty pharmacy, and hospital management programs.
New Manufacturing Contracts Create Prior Auth Follow-Up Backlog
When one of the specialty pharmacies won an exclusive contract to distribute a new psoriasis drug, the pharmacy leaders knew they would have to add more staff to handle their prior authorization follow-ups needed to deliver timely patient care.
They were already struggling to stay on top of their current backlog. These two pharmacies constantly advertised and used a recruiter to find new staff members. They even had their own staff members working overtime.
Complicating matters, the high rate of new staff attrition (an industry wide phenomenon) meant the pharmacy’s prior authorization capacity constantly became overwhelmed. When a new employee did come on, their learning curve for the pharmacy’s proprietary system only increased labor costs. In addition to staffing challenges, pharmacy leaders were also frustrated that the same errors arose repeatedly in their prior authorizations.
Pharmacy Seeks A Flexible And More Experienced Partner
The chief pharmacy officer and vice president of operations began their search for a solution. They evaluated several vendors, but their parent company had used us for data entry and billing tasks for years. They wanted a partner that knew their business and systems, and also had the capacity to handle a large influx of data.
They chose us to handle their prior authorization follow-ups for prior authorizations that would be required for the new psoriasis drug. The pharmacies would initiate all prior authorizations. Once that influx was processed, the client would re-evaluate whether they would remain with our workforce or bring on their own new staff.
Infinx Unleashes Specialists On Backlog
Within days of signing the contract, our supervisors and specialists began learning the client’s prior authorization workflow. Every 24 to 48 hours, our specialists follow up with the payers on previously submitted prior authorizations, clarifying with the pharmacy when needed.
When additional information is needed, the prior authorization is kept under ‘Pending’ status in the client’s proprietary pharmacy system, which triggers additional follow-ups every 24 to 48 hours. When these issues are resolved, the prior authorization status is updated as ‘Approved,’ and the claims get paid. Any rejected prior authorizations go back to our specialists to be reworked.
Relevant data entry involves creating and updating patient profiles, diagnosis, clinicals (ICD), medication, and running test claim to verify insurance. We also handle faxing refill requests to the physician offices.
To keep prior authorization workflow accelerating and improving, we monitor and consistently improve our team’s accuracy using our unique quality/assurance process. This system has enabled us to deliver highly accurate work in a cost-effective manner.
Specialty Pharmacy Only Pays For Fully Trained FTEs
From the beginning of the partnership, despite the fact that our specialists were new to the client and their system, we could guarantee that each of our full time employees matched the pharmacy staff’s efficiency. We do it by overstaffing specialists for each role, but charging only for one FTE until our staff is fully ramped up. Furthermore, our supervisors have onboarded many new clients and are efficient trainers. This approach allows us to train and equip employees as quickly as possible and help the client avoid training costs.
Streamlined Prior Authorization Follow-Up Allows Pharmacies To Continue Expansion
We went live within a month of taking on the accounts. We were fielding 200 prior authorizations for the new psoriasis drug per day and resolving 120. Within 2 months, we had cleared their entire backlog. The errors their own staff tended to repeat are now eradicated. Even with the new psoriasis drug prior authorization influx taken care of, the client has decided to continue with us rather than bring on their own staff.
The client also appreciates that our workforce is available all holidays, weekends, and evenings year-round, and that they don’t see fluctuations in our work quality due to turnover. They consistently award us a 10/10 Net Promoter Score.
Our support has given these pharmacies the ability to reassure drug manufacturers looking for distribution partners that they have a robust prior authorization process in place.
If you are looking to achieve similar results at your organization, contact us at www.infinx.com/request-a-demo.
Is your pharmacy pursuing opportunities to dispense new medications? You’ve probably learned that payers demand robust, accurate documentation before approving a new drug prior authorization. See how one specialty pharmacy used a tech-enabled prior authorization solution to get approval and satisfy an influx of new medication requests.