Prescriber Referral Process Key to Success in Specialty Therapies

The flow of Information is essential when it comes to prescribers sending referrals to specialty pharmacies (SP).

Too often, prescribers will transmit a referral to a SP and not receive a response for days, or even weeks. The prescribers or their staff often wonder, why does it take so long for a SP to process a prescription, or why is there not more direct communication between the 2 facilities?

The answer to these 2 questions often varies from pharmacy to pharmacy, but the overall metric that concerns each stakeholder is regarding the time-to-fill. To reduce this metric, the SP and the prescribers must complement each other to optimize patient outcomes.

The SP must act as a medication resource center that the prescribers can reference and look to for support. Also, the SP must maintain enough bandwidth in order to field any calls or referrals that the prescribers send in, as close to real-time as possible.

The referral process should begin with a detailed medication referral form, often created by the particular SP that will be processing the claim. It should include all pertinent information about the patient, their disease progression, past medical history, insurance information, and any information that will help successfully adjudicate the claim.

Each SP must periodically update their referral forms to ensure accurate information. Outdated information will only increase time-to-fill. The conversion to ICD-10 codes is a perfect example.

Simply creating referral forms does not decrease time-to-fill, unless the prescriber has access to the forms. Each SP should utilize a sales force to ensure prescribers are well-educated on the location of their referrals.

Once the referral has been completed by the prescribers, it must be successfully sent to the SP. The prescribers often are left in the dark when, if at all, the referral is received correctly by the SP.

To streamline this process, a receipt of acknowledgment should be sent back to the prescriber by the SP to close the gap on whether the claim has been initiated. The information sent can be as simple as the patient's name, medication, date of receipt, and all pertinent contact info for the SP, including a single point-of-contact, if applicable.

The referral can now be data entered into the pharmacy’s computer system, as well as any additional clinical information, including a complete medication list, disease progression, and previously failed therapies. Next, the referral should be data verified by a trained specialty pharmacist to ensure the most appropriate drug regimen possible.

If the prescriptions had any therapeutic or quality issues associated with the referral, the prescriber must be contacted immediately to resolve the issue. This should be completed the same business day that the referral was received.

Communication the same business day is crucial, as many specialists have multiple offices and different staff members at each one. A quick outreach will increase the likelihood of a successful clarification or medication alteration.

When the prescription has been validated with no therapeutic or quality-related issues, then the prescription is eligible to be adjudicated to the third party payer. The adjudication of any referral can lead to several different conclusions.

The claim can be paid, denied, or restricted to a limited network. Efficient processing is crucial to decrease the time-to-fill for any specialty product.

In an ideal situation, the referral will pay with a reasonable copay, and then can be forwarded to patient care coordinators or clinical staff to contact the patient to start therapy. Unfortunately, this is not the most common outcome from referral adjudication.

Often, the claim is denied, and a prior authorization is needed from the prescriber, or paid with an unreasonable copay. The claim must now be passed on to the insurance verification team to investigate the claim in detail.

At this point, the patient should be contacted and informed of the referral, and any adjudication-related issues, including the additional time necessary to complete the claim. This allows the patient to know their referral has been received, and the SP is working the claim.

The SP can use this as an opportunity to introduce all of their services. The insurance verification team must now contact the patient’s benefits department and discover the true nature of the denial.

Prior authorizations are the most common denial from any third party payer. The insurance team must be able to provide precise prior authorization forms to the prescriber.

The SP referrals should allow its staff to act as an agent on behalf of the prescribers, to initiate and then execute the prior authorization process with a prescriber’s signature. This step can bypass the prescriber’s intervention for some payers, but others still require the prescribers or their staff to intervene.

When the prescriber’s intervention is still necessary, the prior authorization forms must be completed for the prescribers, as much as possible to decrease the time-to-fill. Communication is key during this step of the referral process, as any delays will directly increase time-to-fill.

The SP must be in constant contact with both the prescribers and the payers to ensure the referral is approved or denied in an appropriate time frame. For example, a SP must verify if the prescriber's staff has sent the completed prior authorization paperwork into the payer.

Too often, faxes are misplaced or forgotten about, so it is the responsibility of the SP to follow-up on each claim. Once the claim has been received by the payer, it is now time to start the clock on monitoring the claim.

The vast majority of prior authorizations take 72 hours or more to complete, while some can be expedited as quickly as 24 hours. The SP should schedule follow-up calls for the payer based on the urgency of the prescription.

Ideally, the SP should know before, or at the same time as the prescribers, whether the claim was approved or denied. If denied, the SP should help initiate the appeal and assist in determining the cause of the denial, and use it as a teaching opportunity.

SP's should have a definitive procedure on how to handle assistance from drug manufacturers, and foundations to decrease patient out of pocket expenses. Overall, from an insurance standpoint, the price should be low enough for the patient to be able to start and maintain therapy.

Therapies patients cannot afford do not benefit any of the stakeholders in their care. The SP should send a final confirmation fax to the prescriber once all financial options are exhausted.

It should contain the patient's name, medication, final out-of-pocket expense, and the breakdown of the cost. The relationship between the prescribers and the SP must be precise, efficient, and thorough.

Each referral should be assessed on the time-to-fill, along with the out-of-pocket expense; both should be as minimal as possible for the best patient outcomes.

Each SP has the responsibility to help drive each successful therapy. The better the relationship with the prescribers, the more likely the prescribers are to utilize the SP for their referrals.

About the Author

Anthony Mazzarese is a graduate of The University of Pittsburgh School of Pharmacy and is currently enrolled in the Masters of Science in Pharmacy Business Administration (MSPBA) program at the University of Pittsburgh, a 12-month, executive-style graduate education program designed for working professionals striving to be tomorrow’s leaders in the business of medicines. He is the Pharmacist-In-Charge at Giant Eagle Specialty Pharmacy. His practice is focused on improving medication compliance and overall wellbeing in the areas of HIV, auto-immune disorders, oncology, and organ transplantation.