Implementation of a comprehensive medication prior-authorization service.

Abstract

The development and successful implementation of a comprehensive medication prior-authorization service are described. At our 550-bed academic medical center, we found an increasing number of Medicare write-offs as a result of the off-label use of specialty medications. Furthermore, more insurers were requiring that prior authorization be attained before patients began treatment with a high-cost specialty medication. After investigating who was pursuing these prior authorizations and where they were documented, it became clear that no department within the hospital owned this responsibility. Our pharmacy department initiated a specialty medication prior-authorization and medication assistance program to review all medication orders written for high-cost specialty medications administered or infused in any of the health system's outpatient clinics, including chemotherapy infusions. A full-time specialty pharmacy coordinator was hired in fall 2010. This pharmacist was responsible for spearheading the overall specialty medication strategy for the health system. Our prior-authorization work across our health system has not only helped to reduce Medicare write-offs and commercial insurance denials but also has resulted in closer working relationships with individuals in other departments of the hospital. Several million dollars in additional write-offs were avoided because our prior-authorization staff identified prescribed therapies that would not be covered by Medicare or commercial insurers before they were started. In total, we decreased write-offs or increased revenues by over $6.2 million during this time frame, a return on investment exceeding 20:1. A comprehensive medication prior-authorization service generated additional revenue due to a decrease in lost charges and an increase in net reimbursement.