ASHP Best Practices Award Mortar and Pestle

Award Information

Institutional and Patient Benefits of a Comprehensive Medication Prior Authorization Service

Robert J. Leinss, Jr., R.Ph., M.B.A., Binita Patel, Pharm.D., Todd Karpinski, Pharm.D., M.S., FASHP, Sue Derus, M.B.A., RT(T), ARRT, Emily Blend, M.B.A, M.S.N., R.N., Jennifer Underly, M.S., Roberta A. Navarro, B.S.N., R.N.


Froedtert Health and the Medical Colllege of Wisconsin, Milwaukee, Wisconsin

Insurers increasingly require prior authorizations (PA) for high cost, specialty medications before reimbursement.  Without a PA, insurers deny coverage, costing health providers millions of dollars in revenues.  Medicare does not require PAs, but publishes clear guidelines on the indications they will cover.  Not following these guidelines can result in Medicare write-offs that further reduce reimbursement.

As part of our overall specialty pharmacy strategy, we first reviewed Medicare coverage guidelines pertaining to the key specialty medications that were being written off.  These same guidelines are also used by many commercial insurers.  We met with the clinics and providers where those orders originated to determine their current process for acquiring PAs.  We found that no clear process existed.  That led to our decision to hire our first medication PA specialist to acquire PAs for our GI clinic and cancer center.

We hired additional PA specialists to handle PAs for the specialty medications dispensed from our outpatient pharmacies for discharge and cancer patients. These medications often have high co-pays so we began pursuing co-pay assistance for patients who could not afford their co-pays. This became a large patient satisfier and improved compliance.  We also pursued medication assistance programs for inpatients and outpatients who did not have health insurance.  This ensured that our patients would get the medications they needed and helped avoid unnecessary re-admissions. We also reviewed all standard of care arms of proposed drug studies to ensure enrolled patients were not surprised by an insurance or Medicare denial when they began treatment

We actively participated in getting several Medicare local coverage determinations changed as a result of submitting literature that supported new uses for existing medications.  We began a drug repository that allowed us to accept unopened, sealed medications from patients who no longer needed them.  Instead of disposing of the medications, the state of Wisconsin allowed us to re-dispense them free of charge to patients who do not have health insurance.  This resulted in over $250,000 in free medications provided to patients in the first year alone.

In the first six months of 2013, our staff recoded almost $4 million worth of Medicare claims that would have been written off.  We avoided several million dollars in additional write-offs by identifying prescribed therapies that would not be covered and notifying the prescriber before they were given.  During this same time we generated patient or system savings of over $6.2 million as a result of our medication and co-pay assistance program efforts.  This work alone increased patient satisfaction markedly and expanded the number of patients who can get the medications they need.   This program has expanded the visibility and positive impact the pharmacy department has on improving patient care.

View a pdf of the poster from the Midyear Meeting (259 KB)