Prior Authorizations and (Micro)managed Care

Denial of coverage can be frustrating. Here’s how you as a clinician can handle these situations.

SCARIEST IN PSYCHIATRY

In this series, Scariest in Psychiatry, we asked clinicians about the scariest topic in mental health. What’s frightening, worrisome, or concerning in psychiatry? Here’s how they answered.

During my first year working at a community mental health center (CMHC) in New Hampshire, there was a moratorium on prior authorizations for patients with state Medicaid insurance. This was due to strong advocacy efforts with state legislature by one of my psychiatrist colleagues at the CMHC, and other dedicated stakeholders. This was great… until it ended.

My nurse practitioner program prepared well me for many facets of patient care, but an area that was not addressed was the concept of prior authorizations and the potential challenges faced by insurance formularies. My first experiences left me thinking, What do you mean I went through all of this training to select the best possible medication for my patient, and now I am being told I cannot prescribe that? The idea of someone who has never met or assessed the patient making these judgment calls is difficult to sit with, especially when medications that have proven to be efficacious for a patient when nothing else has are no longer covered or the coverage is declined.

Although this is incredibly frustrating and discouraging for me as a clinician, ultimately the patient is suffering the burden of these systems. The timeline for prior authorization reviews can further cause impairment and harm to patients. Often, for what most of us would consider a reasonable and timely review, one must request what is called an “expedited” review. That, of course, has a particular process as well. In a survey of physicians collected by the American Medical Association (AMA) in 2021, it was noted that 93% of patient treatments requiring prior authorization were delayed.1 This survey noted as well that treatments that required prior authorization were felt to have had a negative impact on care 91% of the time.1 Inefficiencies of the existing prior authorization systems has reached a level of national political priority, and this has resulted in legislative efforts to support an electronic prior authorization process for Medicare Advantage plans.2

Although I have not solved this large-scale barrier and systemic challenge faced by clinicians and patients all over the country, I have found some value in figuring out how to best approach these situations when otherwise I might feel powerless. As an educator training psychiatric-mental health nurse practitioners (PMHNPs), I have worked to integrate the knowledge of this issue into our curriculum so that graduates are prepared for the possibility of the medication determined to be best for their patient not being covered or initially declined. It is challenging for a clinician entering the field to reconcile this fact. I found that to be a very hard pill to swallow, if you will. It was so hard to swallow that I would have requested a sublingual formulation—but that would have been denied, I’m sure.

Here are some of the recommendations that I have found to be useful in these situations:

1. Obtain a comprehensive psychiatric medication history. This is imperative to incorporate within psychiatric interviewing to ensure we are providing safe and high-quality care. However, documenting a highly detailed medication history can provide incredible value when faced with denial of a medication. Take note of the specific medications that the patients took and the dosing if known, along with any benefits, adverse effects, and reasons for discontinuation. I make sure that this is documented clearly and reviewed periodically. Including the date that the medication history list was obtained is helpful for the clinician because, depending on the records system, it may not be clear when it was last reviewed and updated. It is helpful to keep the list up to date and to revisit with any changes or new information from the patient, previous records, or other sources. See examples in Tables 1 and 2. There have been times when a medication has been denied and the formulary suggestions letter comes back, only to recommend medications that the patient has in fact already tried and failed. Having this documented to send with consideration for appeal has helped to overturn several medication denials.

2. Though this does not directly impact the result of the authorization, I find it to be very helpful to have a transparent conversation with patients about prior authorizations and what to expect. It may feel like precious appointment time spent discussing “what-ifs,” but this facilitates patient self-efficacy, and they may be better able to advocate for themselves when they are aware of these systemic processes. Communication gaps are inevitable, and if the clinician does not receive notification of prior authorization requirement—which does happen frequently—having the patient as a conduit to ensure that all involved parties are aware of what is happening is quite beneficial. This can help to minimize delays with the approval process as well. Patients can contact their insurance companies as well to address denials or other coverage issues. It may help the patient to better understand the source of these delays as well, and to utilize their valuable time accordingly.

3. Consider writing an appeal to the insurance company or request a peer-to-peer review. There is some variability in the peer-to-peer review request process depending on the state where care is taking place, along with the patient’s insurance. Typically, the information for facilitating the next step should be documented on the notification of the denial of medication coverage. These letters are often sent to the clinician’s office and to the patient’s home address.

I have written many appeal letters and requested peer-to-peer reviews. Some have been successful, and others have not. I have yet to uncover a magic formula for this, but I find that documenting a comprehensive review of medication history and trials, rationale for medication selection, and presentation of risks of not having that medication are all quite helpful to include. I have pulled in literature support and clinical guidelines to validate my requests in the past. As someone who has shifted to primarily academic work in recent years, I have more of an appreciation for this now than I did when I was exclusively working in clinical practice! Granted, I have access to an extensive online library database through my university, but there are many accessible and free resources available for clinicians, not to mention health care agency subscriptions. This can even be a helpful rationale to support a request to your employer for access to some of these materials to support prior authorizations.

Even if the appeal is then denied, I find that patients are appreciative of this additional effort and recognize the challenges of going up against a powerful system. One patient case stands out in my mind, as I had a patient with severe, chronic, treatment-resistant depression who finally began to respond to a combination of treatments with significant improvement of symptoms. We initiated this regimen with samples, and upon seeking to continue this via the pharmacy, insurance coverage denied it. This inspired the patient’s passion for advocacy and led them to become an active political participant at a state level. It was incredible to see someone who had suffered for so long and lacked motivation and a sense of purpose become invigorated by the idea of making a larger impact difference and helping others.

Requesting a peer-to-peer review is an option in many cases as well, although sometimes the peer that is offered for the call is not in fact an intraprofessional colleague, but may be a colleague from another discipline. Unfortunately, I had a particularly negative interaction during a peer-to-peer review several years ago, which I wrote about in my previous piece, “Partnering for the Greater Good.” This person chose to criticize my training and background, even though I was practicing legally within my scope and congruently with regulations in my state. That individual used his own bias and opinions about my training as his rationale for denying the patient’s medications. I remained calm throughout the interaction and sought out support from a psychiatrist colleague, and ultimately, we went to the insurance company to file a complaint about the issue. As it turns out, the entire call was recorded, and their brazen lack of professionalism was clear. The individual was held accountable—and most importantly, the patient’s medication ended up being covered.

In this case, the patient had many changes as far as living situation and transitions of care, which made gathering comprehensive previous records challenging. Some records were obtained, but not all treatment records were available, which is not uncommon. This patient had previously been quite unstable for a period of time, with multiple psychiatric inpatient hospitalizations and medication changes, but more recently had maintained a prolonged period of stability on the current medication regimen. By collecting a comprehensive medication history at intake and ongoing, along with collecting previous records whenever possible, having that supportive documentation to justify the continuation of the regimen was imperative and well-documented.

4. Familiarize yourself with your state laws and guidelines around prior authorizations, and review formularies for the primary insurance companies that you see patients within periodically. There are some smart phone apps that can facilitate formulary checking as well. Additionally, the AMA compiled a Prior Authorization State Law Chart, which provides specific regulations for each US state.3

Prior authorization reform has been pursued on a national level, but so far there has been minimal progress.4 In New Hampshire, the moratorium on prior authorizations was evaluated for extension and had substantial support, although the opposition was fierce and ultimately it did not continue.5

Concluding Thoughts

As psychiatric clinicians, we know that these authorizations are not only impactful on medication prescribing, but also on inpatient psychiatric hospitalization lengths of stay and justification of levels of care. Services, facilities, and clinicians are all limited, which negatively impacts access to care. Of further concern is when these services are justifiably accessed and there is an external decisionmaker dictating length of stay appropriateness.

I find solace in discussing these situations with my colleagues and peers, and I look to continue working with other passionate advocates for mental health treatment access and equity to address these treatment-interfering systemic barriers to optimal care.

Mrs Robinsonis a psychiatric-mental health nurse practitioner in the Seacoast, New Hampshire, area, and a clinical assistant professor and program director of the Psychiatric-Mental Health Nurse Practitioner Programs, Department of Nursing, University of New Hampshire, Durham.

References

1. 2021 AMA prior authorization (PA) physician survey. American Medical Association. 2022. https://www.ama-assn.org/system/files/prior-authorization-survey.pdf

2. King R. House committee advances bill to install new prior authorization reforms for Medicare Advantage. FierceHealthcare. July 27, 2022. Accessed October 6, 2022. https://www.fiercehealthcare.com/payers/house-committee-advances-bill-install-new-prior-authorization-reforms-medicare-advantage#:~:text=The%20legislation%20would%20require%20the,for%20newer%20and%20pricier%20treatments

3. 2021 Prior Authorization State Law Chart. American Medical Association. 2021. Accessed October 6, 2022. https://www.ama-assn.org/system/files/2021-04/pa-state-chart.pdf

4. Gaines ME, Auleta AD, Berwick DM. Changing the game of prior authorization: the patient perspective. JAMA. 2020;323(8):705-706.

5. Mara D. Prior authorization for drugs to treat mental illness is a public safety problem. Portsmouth Herald. April 26, 2016. Accessed October 6, 2022. https://www.seacoastonline.com/story/news/local/portsmouth-herald/2016/04/29/prior-authorization-for-drugs-to/31067409007/