Implement Pharmacy-Managed Precertification


June 2019 - Vol. 16 No. 6 - Page #2

PART 2 of a 3-PART SERIES on Revenue Integrity

This article is Part 2 of a 3-part series on financial management in the pharmacy. Part 1, The Pharmacist’s Role in Ensuring Revenue Integrity (pppmag.com/article/2326), appeared in the December 2018 issue of Pharmacy Purchasing & Products. Part 3 will discuss revenue cycle charge integrity and reimbursement and will appear in a future issue.

In an era of soaring drug prices, payers have developed complex strategies to manage costs and ensure clinically appropriate prescribing in the outpatient environment. Health systems that do not proactively seek to understand and comply with these payer-mandated requirements risk significant revenue losses. However, navigating these often burdensome rules can be challenging for providers and clinic support staff, especially those who are not well-versed in medical billing or precertification requirements.

There are four critical elements of medical benefit precertification that health systems must manage:

  • Patients’ medical benefits investigation
  • Drug prior authorization
  • Medical necessity policy verification
  • Coverage predetermination

It is common for administrative, nursing, and pharmacy staff to share precertification responsibilities; however, a lack of process ownership can result in treatment without payer approval, missed steps, and costly errors. Health systems that invest in creating standardized precertification strategies help ensure that the appropriate steps are taken to maximize efficiency and minimize denials. Implementing a comprehensive, closed-loop, pharmacy-centric, precertification strategy is one method that has proven to protect institutional revenue while also supporting a patient care focus.

Pharmacy Ownership of the Pre-Certification Process

Leveraging precertification responsibility within the pharmacy department is a unique financial management strategy that allows key pharmacy personnel to assume ownership of each step of the process. By bearing the expense of these services and protecting revenue, a pharmacy-managed precertification process, in alignment with a pharmacy-managed revenue integrity program (as described in Part 1 of this series), helps minimize revenue leakage and increase savings for both patients and the institution.1

In 2014, pharmacy department leadership at the University of North Carolina (UNC) Medical Center, with support from senior hospital leadership, implemented a requirement to develop a medical benefit precertification program in the outpatient setting. The pharmacy’s medication assistance program team was already overseeing manufacturers’ free drug programs, prescription benefit prior authorizations, copay assistance for select specialty drug therapies, and the pharmacy’s internal charity care program; overseeing medical benefit precertification was a logical addition to these responsibilities.

Program Infrastructure

UNC Medical Center’s precertification process relies on the services of the medication assistance program team, the operations pharmacist(s) located in the infusion center pharmacies, and the pharmacy revenue integrity team. When an order is placed through the electronic health record that contains a drug or drug class that payers require precertification for coverage, an electronic referral is automatically routed to the medication assistance program team, initiating the precertification process. The medication assistance team includes a nurse, who conducts medical necessity reviews, and medication assistance specialists (certified pharmacy technicians), who perform comprehensive benefits investigations and complete prior authorizations, as required.

To facilitate a smooth precertification process, an institutional policy requires that outpatient infusion orders be placed at least 7 days prior to treatment and that payer authorization be on file before pharmacy dispensation of the infusion. The four key steps of the precertification process are:

  1. Patients’ Medical Benefits Investigation. The benefits investigation process requires a thorough review to determine the patient’s health insurance plan’s expected coverage and the patient’s out-of-pocket responsibility.
  2. Drug Prior Authorization. Prior authorization requires that providers obtain approval from payers to prescribe certain medications. If a prior authorization is required, the medication assistance specialist reviews the patient’s chart for pertinent clinical information, retrieves any additional information from the patient’s provider, and submits the prior authorization request, tracking it through to completion.
  3. Medical Necessity Policy Review. The medical necessity policy review, an increasingly complex component of the precertification process, involves verifying a plan’s medical policies to ensure that the necessary clinical documentation is available to meet payer guidelines. This step is completed by a nurse, as it requires in-depth clinical assessment to verify that a comprehensive evaluation of policies occurs.
  4. Coverage Pre-Determination. The medical necessity review determines if a request to the payer for coverage pre-determination is required.

Throughout each of these steps, active communication with the patient care team and clear documentation in the electronic health record are essential.

Key Players

The Role of the Medication Assistance Team

In addition to managing precertification, the medication assistance team enrolls eligible patients into manufacturers’ patient assistance programs, thereby enabling patients’ drug access without relying on the institution to absorb this expense or causing the patient financial toxicity.

The Functions of the Operations Pharmacist

The operations pharmacist(s) assigned to the outpatient infusion center where the patient receives their infusions is an integral participant in the precertification process. At least 48 hours prior to a patient’s scheduled clinic visit, the pharmacist checks the infusion referral to verify its authorization. If not yet authorized, the pharmacist follows up with the medication assistance specialist to expedite the case and coordinates with the patient’s provider and the clinic scheduling team to reschedule the patient’s visit (if needed). The role of the operations pharmacist is critical, as this individual confirms that drugs that are not yet payer-approved are not dispensed, in compliance with institutional policy.

Facilitating a Collaborative Process

A robust, collaborative process promotes continuous feedback, which fosters open communication and consistent quality improvement. The revenue integrity team pharmacist meets with the precertification medication assistance program team on a regular basis to discuss and navigate intricate issues surrounding denials and appeals, and to brainstorm practice improvements based on their experience.

The medication assistance program team and operations pharmacists are vital to the success of the pharmacy-managed, closed-loop precertification model. The partnership between these two groups reduces the administrative burden on providers and clinic staff and showcases fiscal responsibility to health system administration. In addition, alignment of the precertification team with the pharmacy-managed revenue integrity team encourages both teams to utilize best practices to avoid future denials and write-offs.

Conclusion

In recent years, all departments within the UNC Medical Center have experienced increasing pressure to provide value to the organization. Developing a comprehensive, closed-loop, pharmacy-managed precertification process allows the pharmacy to not only demonstrate fiscal responsibility to the institution, but also to help patients navigate barriers to drug access and reduce their exposure to financial stress. Implementing a comprehensive, well-coordinated approach to the precertification process allows pharmacy to position itself as an influential contributor to the institution’s financial well-being while simultaneously improving patient outcomes.


Reference

    1. Petrovskis MG, Misita C, Amerine LB. The pharmacist’s role in ensuring revenue integrity. Pharm Purch Prod. 2018;15(12):2,4.

Stephanie J. Jean, PharmD, BCPS, is a health-system pharmacy administration resident at the University of North Carolina (UNC) Medical Center in Chapel Hill, North Carolina. She earned her Doctor of Pharmacy from the UNC Eshelman School of Pharmacy. Stephanie’s professional interests include practice advancement, ambulatory care management, clinical management, and transitions of care.

Suzanne J. Francart, PharmD, BCPS, is the assistant director of pharmacy for the medication assistance program at the UNC Medical Center. She earned her Doctor of Pharmacy from the Virginia Commonwealth University School of Pharmacy, then completed a PGY1 general practice residency and PGY2 pharmacotherapy specialty residency at UNC Hospitals. Suzanne’s professional interests include ensuring patient drug access and institutional financial stewardship.

Lindsey B. Amerine, PharmD, MS, BCPS, is the director of pharmacy at the UNC Medical Center and an associate professor of clinical education for the division of practice advancement and clinical education at the UNC Eshelman School of Pharmacy in Chapel Hill, North Carolina. Lindsey earned her Doctor of Pharmacy from the University of Wyoming School of Pharmacy and her MS with an emphasis in health-system pharmacy administration from the UNC Eshelman School of Pharmacy while completing a 2-year health system pharmacy administration residency at UNC Hospitals.

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