Dr Christopher Phillips on Prior Authorization and Step Therapy in Rheumatology


Christopher Phillips, MD, a rheumatologist in Kentucky, discusses the back-and-forth that providers have with insurers in trying to get therapies approved for reimbursement.

Providers often have to go through multiple steps in order to get some therapies approved, according to Christopher Phillips, MD, a rheumatologist in Kentucky.


Do insurers communicate about prior authorization and step therapy at the same time, or is it more of a linear process?

No, they usually go in tandem, right? I mean, so we submit a prior authorization request. And whenever that's turned around, there may be an approval or a denial and the denials are often kind of wedded with the statement that you've either not provided adequate information, or the patient has to try this other therapy first. You know, the irony is that—I was talking with my own staff a few weeks ago about this—occasionally they'll send a request for more information, and it may come on a Friday afternoon, with 48 hour turnaround time that you have to get it back. And that is not business hours, that's actual hours. So Monday morning comes and your time is up, you know, and you can go back and resubmit that, but it's just a delay, and that happens all the time. And as we go through the process, if we get a denial, and there's a step therapy protocol that there's a certain other treatment that's required first, that for any number of reasons that that may not be the right treatment for the patient. And we may need to submit more records. We may ask for a peer to peer and that's not uncommon. When we get peer to peers the problem with those is sometimes it's rare that we get a specialist in our field, right? We may submitting a rheumatology prior authorization—the peer may be a pediatrician or a radiologist or family practitioner who's, you know, that's just what they do working for that insurer. You know, there's just so many so many barriers. I mean, it goes okay, sometimes, but there's so many ways and times that it doesn't, or that these delays pop up for these various reasons. And, you know, just delay care. And I think that the cynics among us would submit that some of these burdens and hurdles are in hopes that even a small number of patients or physicians kind of drop off or give up and the data supports the idea that happens, right? That if patients have been told by their pharmacy that the treatments not available because hasn't been approved yet that some percentage of them don't ever go on that treatment, just for various reasons.

Does electronic authorizing of prior authorization help at all, or does it just speed the time to a denial?

Well, I mean, yes and no. I mean, yes, it's helpful to have the electronic process. And that's certainly something that we from an advocacy perspective, we've pushed for that. We've pushed for kind of a universal process as well, because, you know, it's one thing to be electronic. And it's another one, every different payer has a different portal and pathway for that. So it probably does speed things up. It's much better than a paper fax system. But it certainly doesn't improve the odds of approval, it may speed the process of being told that more information is needed, or that there is a denial or whatever. So we're definitely in favor of electronic processes. You know, we're in favor of universal kind of systems that are the same process that different payers would use as well.

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