Medication preauthorizations are an essential but often frustrating part of clinical practice, particularly for those prescribing psychiatric medications. This process, designed to ensure that prescribed medications are appropriate and cost-effective, often leads to rework—resubmitting requests, correcting errors, and addressing issues that arise during the approval process. 

Rework not only delays patient care but also increases workload and contributes to clinician burnout. This article aims to provide strategies to reduce rework in medication preauthorizations, ultimately streamlining the process and reducing appeals and calls from insurers and independent review organizations. Additionally, the article emphasizes the need for ongoing education as preauthorization rules continue to evolve.

The Theory vs. Practice of Preauthorization

Preauthorization for expensive medications theoretically ensures that cost-effective and appropriate treatments are selected. However, in practice, insurer guidelines often lack clinician input, leading to ill-informed decisions. This is particularly problematic with new psychiatric medications that often offer minimal improvements in efficacy (Andrade JKL et al, Community Ment Health J 2023;59(3):451-458). Examples include:

• Jornay (methylphenidate)
• Loreev (lorazepam)
• Qulbree (viloxazine)
• Auvelity
• Orally disintegrating pills

These medications are marketed as the newest best options but often have narrow indications, making approval difficult. For instance, the olanzapine/fluoxetine combination pill costs significantly more than its components without added efficacy, highlighting the disconnect between marketing and clinical value.

Strategies to Avoid Rework in Preauthorizations

To reduce additional time involved in such issues, it’s crucial to provide thorough documentation on the initial preauthorization form. This documentation should be specific to the medication's narrow indications to avoid denials and appeals. Key strategies include:

Documenting Specific Indications. When prescribing Jornay, for example, explain why generic methylphenidate is not suitable. Use standardized scales like DPREMB or DAYAS-P to document early AM dysfunction.

Accurate Coding and Detailed Chart Notes: In cases like bipolar depression, use the correct diagnostic codes and document contraindications to alternative medications (eg, quetiapine) with detailed chart notes.

Justifying Specific Formulations. For patients requiring chewable or liquid forms of medication, justify why alternatives like capsule sprinkles are not appropriate.

Comprehensive Medication Documentation. Ensure chart documentation includes detailed information about previous medications, including dose, date, duration, and outcome.

Supporting Scholarly Evidence. When submitting requests that exceed FDA limits, such as for amphetamines for ADHD, include scholarly articles supporting the off-label use (Cortese, S, Expert Opin Pharmacother 2023;24(4):425-434).

Rationale for Brand Over Generic. Brand medications are almost never approved over generics unless there is documented evidence of allergy or significant side effects.

Continuity of Therapy with Samples. Starting patients on samples is not considered a continuation of therapy unless specific conditions are met.

Adhering to FDA Guidelines for New Drugs. When trying to get new drugs like zuranolone covered, follow the FDA label exactly to avoid rework.

Conclusion

Reducing rework in medication preauthorizations is essential for improving efficiency, reducing clinician workload, and ensuring timely patient care. By thoroughly documenting the specific indications, providing accurate coding and chart notes, and following the outlined strategies, clinicians can significantly reduce the likelihood of rework. As preauthorization rules continue to evolve, ongoing education and adherence to best practices will be key to minimizing the burden on healthcare providers.

Further reading

• Aiken C and Quinones-Laracunte K, Stimulant Dosing Limits. The Carlat Psychiatry Report 2023;21(8):1.
• Andrade JKL et al, Community Ment Health J 2023;59(3):451-458.
• Cortese S, Expert Opin Pharmacother 2023;24(4):425-434.
• Use of Prior Authorization in Medicare Advantage Exceeded 46 Million Requests in 2022
• Fixing prior auth: 40-plus prior authorizations a week is way too many