What is the life cycle of a Prior Authorization (PA) request from receipt to review, using Hayes and McG (Medical Guidelines) criteria, and how do policy and certificate differ in this context?

The Life Cycle of a Prior Authorization (PA) Request: From Receipt to Review

Prior authorization (PA) requests involve a complex, multistep process that requires coordination between healthcare providers, staff, and insurance companies to ensure appropriate access to medications and services while managing healthcare costs.

Initial Receipt and Documentation

• When a PA request is received, it must include comprehensive patient information including HF phenotype (HFrEF or HFpEF), NYHA functional class, recent LVEF measurements with source documentation, and identification of the specific treatment requested 1
• Documentation should address previous therapies used and rationale for switching to or adding the requested treatment, as well as any known contraindications, adverse effects, and steps to minimize risks 1
• The complexity of the PA process often requires dedicated multidisciplinary clinical teams, including pharmacy professionals and nurses, who are experienced in the nuances of the process 1

Evaluation Using Clinical Criteria

• Hayes and MCG (Medical Guidelines) criteria are commonly used evidence-based tools to evaluate the medical necessity of requested services or medications 1
• These criteria serve as standardized guidelines that help determine whether a requested service meets established clinical standards for appropriateness 1
• Prior authorization frequently relies on proprietary algorithms that may be inconsistent with published literature and/or guidelines, with methodologies varying greatly among payers and regions 1

Policy vs. Certificate Differences

• A policy refers to the insurance company's documented rules and criteria that determine coverage for specific treatments, procedures, or medications 1
• A certificate refers to the member's benefit document that outlines what services are covered under their specific insurance plan 1
• The distinction is important because a PA request may meet clinical criteria according to Hayes or MCG guidelines (policy), but could still be denied if the requested service is not covered under the patient's specific certificate of coverage 1

Review Process and Decision Making

• Once submitted, the PA request undergoes review by the insurance company using their established criteria (Hayes, MCG, or proprietary algorithms) 1
• The review may result in approval, denial, or a request for additional information 2
• Denials are associated with significant treatment delays - a study found that denied PAs were associated with a median 50-day delay to treatment versus 27 days when no PA was required 2
• Despite these delays, 96% of initially denied PAs were eventually approved, raising questions about the value of PA requirements 2

Impact on Patient Care

• PA requirements can create significant burdens for both patients and medical teams, with anxiety around "sticker shock" and concerns about delays 1
• Treatment delays associated with PA requirements can lead to increased medication exposure (such as higher glucocorticoid use) while waiting for approval 2
• Healthcare providers report altering clinical decisions to avoid PA requirements and related burdens, even when the PA medication was clinically appropriate 3

Best Practices for PA Management

• Work with local pharmacy resources and pharmacy professionals to jointly address PA requirements 1
• Document all steps taken in the patient's health record, including appeals when decisions are contrary to best patient care 1
• Implement identification tools within electronic health records to alert staff about medications that frequently require PA, allowing for proactive management 4
• Develop standardized workflows and documentation processes to improve PA efficiency and discharge care coordination 4
• Coordinate care among clinicians to minimize unnecessary duplication of services 1

Common Pitfalls and How to Avoid Them

• Failing to document that delays or interruptions in therapy may cause harm to the patient can lead to unnecessary denials 1
• Nonquantitative treatment limits, such as disproportionately burdensome prior authorization requirements, may be more difficult for regulators to detect than quantitative limits 1
• Inconsistencies between society guidelines allow payers to implement coverage policies that still "align with society guidelines" but are not reflective of best practice 1
• Lack of standardized documentation can result in significant revenue loss - one academic medical center reported over $21 million in charges denied due to PA issues 5

By understanding the complete life cycle of a PA request and implementing efficient processes, healthcare providers can better navigate this complex system to ensure patients receive timely access to appropriate care.