Prior authorizations (PAs) can feel like a maze: confusing, time-consuming, and frequently frustrating. Though PAs are meant to help manage healthcare resources, they’re often a huge obstacle for providers and patients, especially when it comes to specialty medications.  

As Bethesda, Maryland, gastroenterologist Jessica Korman, M.D., told The New York Times  in an opinion video, “When I prescribe a medication, I would say 95% of the time, I have to obtain a prior authorization. We have four full-time employees whose sole focus is on obtaining prior authorization for medications to treat Crohn’s disease and ulcerative colitis. And that’s for just one disease state.”  

Even with dedicated staff to carry the prior authorization load, inefficient processes and information gaps prevent patients from starting or staying on prescribed therapies.

An AMA survey reveals the real impact of prior authorizations: 

• 94% of providers report delays in patient care. 

• 80% say PAs cause patients to abandon treatment. 

• 89% believe PAs harm patient outcomes. 

Recognizing the differences between medical and pharmacy prior authorizations, paired with an end-to-end medication management approach, can transform how quickly patients get access to needed therapies, leading to better health outcomes.

How Prior Authorizations Differ Based on Benefit Type 

Medical benefit PAs typically cover services like surgeries, diagnostic tests, and imaging. Pharmacy benefit PAs cover prescribed medications. Specialty medications, however, are a wild card in these workflows. They may fall under pharmacy or medical benefits, sometimes both. Typically, specialty medications that require clinician involvement, such as an infusion or injection, fall under medical benefits.  

Even if they don’t fall under medical benefits, specialty medications may require prerequisite services, such as genomic testing or radiology screenings, that also require PA under medical benefits. In addition, these drugs may have special handling requirements that limit where they can be dispensed. 

Since medical PAs lack a standardized process, providers rely heavily on manual or semi-automated methods, such as faxing or uploading documents to payer portals. This can create time-consuming, complex workflows that take time away from direct patient care and contribute to clinician burnout.  

In contrast, pharmacy PAs benefit from well-established standards and digital workflows that support more efficient processing of prescriptions.  

These variations add layers of complexity to existing workflows and can create barriers that slow patients’ access to life-changing therapies.

4 Ways End-to-End Medication Management Solves the Maze

1. Improves Efficiency

Implementing electronic prior authorizations (ePA) for both medical and pharmacy benefits minimizes manual data entry and reduces the time spent gathering information. This approach automatically captures patient data, clinical documentation, and payer policies, breaking down data silos that can lead to preventable denials. DrFirst solutions have demonstrated a reduction in clinician time spent on prescription data entry by up to 80%, freeing up time for direct patient care.

2. Reduces Costs

Managing separate systems for medical and pharmacy authorizations adds administrative complexity and costs. An end-to-end solution consolidates benefit verification, patient financial responsibility calculation, PA submission, and more. This simplifies administrative tasks, cutting operational expenses. A national specialty pharmacy saw operational costs associated with each new prescription decline 30% using the DrFirst ePA solution.

3. Enhances Patient Care

A robust medication management system ensures faster PA approvals, leading to more timely access to essential therapies. The benefit doesn’t end with patients, however. Reducing the administrative burden on clinicians leads to greater job satisfaction, because they can focus on patients, not paperwork.

4. Ensures Compliance 

With impending regulations for interoperability and ePA, healthcare providers need compliant, agile, future-proofed solutions. DrFirst uses best-in-class FHIR APIs, meeting the standards set for upcoming rules from the Centers for Medicare & Medicaid Services and the Assistant Secretary for Technology Policy and Office of the National Coordinator for Health Information Technology.

A More Direct Path to Specialty Medications 

With end-to-end medication management, you get more than efficiency. By simplifying workflows, breaking down data-sharing barriers, and harnessing clinical-grade AI, DrFirst empowers healthcare providers to connect patients to the right medications at the right time.