You need preauthorization (P.A) in your specialty pharmacy billing services, also called prior approval or precertification, before your specialty drugs can be covered by insurance. We cannot deny the fact that specialty drugs are not easy to purchase as your pharmacy needs to make those with special formulas and compositions. Furthermore, specialty drugs also come with high price tags and that is why obtaining PA approval in your specialty pharmacy billing services is more challenging than any other medical specialty.

Do you know the reason why insurance companies are going to become more stringent on their prior authorization process in your specialty billing services? The reason is simple- the recent change in the federal administration in the nation. Federal bodies want you to ensure that the specialty drugs that you are going to administer are perfectly apt, medically justified and cost-effective for your patients. The current US administration wants you to be more cautious about your patient’s overall health. Always remember the fact that if you are unable to get prior authorization approvals for specific specialty drugs, you would end up with claim denials for your practice and more surprise bills for your patients. This means the patient could end up paying for the service all by themselves.

Did you know the fact that all the insurance companies will have to adhere to strict timelines for completing prior authorization from 2026? If you send an urgent request, they’ll have to reply in 72 hours, and for regular ones, you will hear back within seven days. This means your patients can get care faster! Plus, if they deny your request, they must tell you exactly why and share their approval stats every year. It’s all about making things clearer and less stressful for you and other healthcare providers.

It is always important to know about the key reasons behind performing prior authorization in your specialty pharmacy billing services so that you can prioritize this process to ensure a highly improved claim submission rate!

Reasons why you need timely prior authorization approvals in the specialty pharmacy billing process

Medical necessity: You know how doctors sometimes need to double-check with your insurance before giving you medicine or treatments? That’s called prior authorization. It’s how your insurance makes sure what you’re getting is really needed for your health.

Cost control: Do you know how insurance helps pick the right treatment for you? They also make sure it’s not too expensive, so it keeps the costs under control while still helping you get better.

Preventive measures: You know how your insurance checks what treatment is best for you? They also make sure it’s not super pricey, so you can get better without breaking the bank!

Now that you know the reasons why PA is a must-have process for your specialty pharmacy billing services, it’s time to learn about the measures to ensure a robust PA process.

Critical steps involved in your prior authorization process

Identify the services requiring PA: You start by checking your health plan and talking to your insurance company about your treatment. You need to make sure the treatment is covered because they look at everything carefully. Then, you send in the request as quickly as you can to get things moving for you!

Submit PA requests promptly: You must send a request to your patient’s insurance company. They’ll include stuff like your lab results, medical records, diagnoses, and a note explaining why you really need this treatment.

Review your PA request: The insurance companies of your patients will scrutinize the submitted PA request carefully to determine if they actually need those specialty drugs. An insurance company always takes the final decision after going through the PA forms and other necessary documents. Remember, it is not necessary that you get a prompt PA approval as sometimes, it may take even a few days to a week.

Process the PA request: After your insurance reviews the request, they will either approve or deny it. If it’s approved, make sure you write down the approval date and code. If it’s denied, talk to the patient right away and plan what to do next, like filing an appeal.

You now know how important prior authorization is for your specialty pharmacy billing services. You can avoid claim denials, save your patients from surprise bills, and ensure they get the care they need by staying on top of the PA process in your specialty pharmacy billing services. Always remember, that a smooth PA process means better outcomes for you and your patients!