Jason Zimmerman, RN, OCN
Specialty pharmacies and prior authorizations are unavoidable aspects of oncology care that often pose challenges for both patients and providers. However, standardization plays a crucial role in simplifying these complex processes, allowing for improved efficiency and optimal patient care, according to Jason Zimmerman, RN, OCN. Standardization also facilitates seamless transitions between healthcare professionals, ensuring continuity of care even when someone is unable to perform their duties.
“Prior authorizations make you want to pull your hair out sometimes, but when it comes to dealing with complex procedures, the more you can standardize them, the more comfortable and efficient you’ll become,” he said at the 2023 AONN+ Midyear Conference in Orlando.
What Is Specialty Pharmacy?
Specialty pharmacies play a vital role in managing rare, chronic, and complex medical conditions. These pharmacies are accredited and designed to handle medications that require special care, personalized education, adherence monitoring, and follow-up. Unlike traditional retail pharmacies, specialty pharmacies provide comprehensive support and ensure patients receive the attention and care they need.
Financial barriers often accompany specialty pharmacy medications due to their high costs and limited distribution networks. “Once you start talking high-cost medications, there’s usually a high out-of-pocket cost, which then creates financial toxicity,” he noted. To address this issue, it’s crucial to ensure that financial assistance options are explored and patients are aware of the resources available to them.
Overcoming Barriers and Streamlining Prior Authorizations
The sheer complexity of the healthcare system poses a number of barriers to the prior authorization process. Currently, there are no exhaustive drug lists or a specific set of criteria outlining which medications are considered specialty medications, and each insurer has different rules and regulations regarding prior authorizations, formulary restrictions, designated specialty pharmacies, etc. Paperwork required by insurance providers can also be burdensome, and when not completed correctly, it can delay treatment (sometimes by up to 10 days).
Spending significant time attempting to contact and communicate with insurers, pharmaceutical companies, and external pharmacies only further complicates this already tedious process. While these processes can be frustrating and time-consuming, it’s important to remember that effective communication, attention to detail, and utilization of available resources can help to mitigate these challenges.
According to Mr Zimmerman, obtaining necessary clinical information about a patient plays a vital role in streamlining prior authorizations and navigating these processes efficiently. “Talk to the doctor, or go in the medical record and find it yourself,” he advised. “You need to have clinical information to fill out these forms.”
Spending significant time attempting to contact and communicate with insurers, pharmaceutical companies, and external pharmacies only further complicates this already tedious process.
Investing time up front is key to streamlining the workflow. Ensuring that a dedicated professional with clinical experience handles these authorizations is crucial. “Clinical experience is invaluable when you’re trying to take care of patients in the best way that you can,” he said. It’s also beneficial to schedule patient appointments in a manner that allows ample time for prior authorization tasks, reducing the pressure of time constraints.
One valuable resource that simplifies the prior authorization process is CoverMyMeds, which provides an intuitive platform for submitting authorization requests. By simply asking users to input patient and medication information, select the appropriate form, and attach any necessary medical records, this platform minimizes redundant paperwork and optimizes communication with insurance companies. “Find an electronic prior authorization process that you’re comfortable with,” he advised. “But in my opinion, CoverMyMeds seems to have the best process and availability for prior authorizations, and it’s the easiest one to work with.”
“In-House” Specialty Pharmacy: The “Easy Way”
Or, you can do it the “easy way,” said Mr Zimmerman. If not already in place, developing an integrated, in-house specialty pharmacy can foster better collaboration, efficiency, and communication.
“Because they’re in-network, they’ll have access to your electronic medical record, which limits back-and-forth communication,” he noted. “They can run the test claims so you have an idea of what the cost will be and whether or not you need to involve a financial navigator, and they can also tell you exactly where it needs to be filled. Compared to working with someone from a completely different company, sometimes people will go that extra mile when you’re on the same team.”
This improved collaboration and communication can equate to wins for all involved stakeholders. Navigators win back more time to spend on navigating patients, and the health system wins because they’re increasing their revenue. But most importantly, patients win by receiving timely access to necessary medications, minimizing their financial burdens, and receiving quality, comprehensive support throughout their healthcare journey.
