Pharmacies doing prior authorizations

[Chrissystone]

Something the owner of my pharmacy is adamant about is not doing prior authorizations for doctors. We can fill out some information should we have the information but he is very serious about not faxing anything to the insurance companies from our fax machine or forging information on the prior authorization forms. If a doctor's office wants us to fill out the demographic information on the prior authorization forms, we will and then fax it to the doctor's office to complete the clinical information.

I've been told from several doctors offices that other pharmacies do it for them, they will call the PBM PA line and answer as if they were calling from the doctor's office or even sign the forms for the doctors. I have no idea how this is legal and when I tell the doctor that they can use the other pharmacy to fill for them, they start yelling at me about how they will never send scripts to my pharmacy again. (Pretty sure, directing scripts for patients is illegal too..) Whenever I call the doctor's office to let them know that there needs to be a prior authorization for the medication, their attitude changes like 180 degrees. The receptionist puts me on hold for over 15 minutes or deliberately hangs up.

So how exactly does a pharmacy do prior authorizations for doctors? Is there a form that the doctors sign to authorize the pharmacy to do this on their behalf? I am looking for some insight as my understanding may be outdated.

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[dblock05]

I have never seen or heard of a retail pharmacy (chains) do a PA for a doctor in the last ten years.

Sounds like the doctor is full of it.

 

[Sparda29]

I have never seen or heard of a retail pharmacy (chains) do a PA for a doctor in the last ten years.

Sounds like the doctor is full of it.

I know a few places.

CoverMyMeds, The Leader In Electronic Prior Authorization

Doctors create accounts for this. Doctors give account info to the pharmacies. Doctor gives authorization for pharmacy to complete these forms and sends the reason for the necessity of the meds as part of the electronic prescription note section. Pharmacy fills it out, sends it in, next day the prescribed medicine is covered. Pharmacy fills it that morning and has it delivered.

 

[Dr Wario]

I can see independents doing something like this since the money goes into directly into their pockets, in chair retail the office gets a fax from us informing them of the need to do the prior auth and that's the end of it.

 

[Chrissystone]

I know a few places.

CoverMyMeds, The Leader In Electronic Prior Authorization

Doctors create accounts for this. Doctors give account info to the pharmacies. Doctor gives authorization for pharmacy to complete these forms and sends the reason for the necessity of the meds as part of the electronic prescription note section. Pharmacy fills it out, sends it in, next day the prescribed medicine is covered. Pharmacy fills it that morning and has it delivered.

That sounds like a really long process to set up. The doctors office would need to include all the information and create the account.

 

[CetiAlphaFive]

I can see independents doing something like this since the money goes into directly into their pockets, in chair retail the office gets a fax from us informing them of the need to do the prior auth and that's the end of it.

Maybe some places.

I get PA forms faxed to me sometimes, and I just write, "this isn't the insurance company. Wrong fax numbernumber"

Something the owner of my pharmacy is adamant about is not doing prior authorizations for doctors. We can fill out some information should we have the information but he is very serious about not faxing anything to the insurance companies from our fax machine or forging information on the prior authorization forms. If a doctor's office wants us to fill out the demographic information on the prior authorization forms, we will and then fax it to the doctor's office to complete the clinical information.

I've been told from several doctors offices that other pharmacies do it for them, they will call the PBM PA line and answer as if they were calling from the doctor's office or even sign the forms for the doctors. I have no idea how this is legal and when I tell the doctor that they can use the other pharmacy to fill for them, they start yelling at me about how they will never send scripts to my pharmacy again. (Pretty sure, directing scripts for patients is illegal too..) Whenever I call the doctor's office to let them know that there needs to be a prior authorization for the medication, their attitude changes like 180 degrees. The receptionist puts me on hold for over 15 minutes or deliberately hangs up.

So how exactly does a pharmacy do prior authorizations for doctors? Is there a form that the doctors sign to authorize the pharmacy to do this on their behalf? I am looking for some insight as my understanding may be outdated.

I can see independents doing something like this since the money goes into directly into their pockets, in chair retail the office gets a fax from us informing them of the need to do the prior auth and that's the end of it.

Yeah, we'd never do that at my independent.

 

[scoopydoo123]

I was working at an independent one. We do it all the time, for the sake of patients. To be honest, whenever I bill something saying PA required -> pharmacist check for drugs -> we techs print out the form -> tax to doctor offices.

 

[Chrissystone]

I was working at an independent one. We do it all the time, for the sake of patients. To be honest, whenever I bill something saying PA required -> pharmacist check for drugs -> we techs print out the form -> tax to doctor offices.

That's understandable but these doctors near me are asking me to fill the whole thing out and do it for them, sign and everything. I told them I cannot make up clinical information and I cannot forge for the doctors office. They got pissy and now are not sending to my pharmacy anymore.

 

[owlegrad]

The doctor is full of it. Surely you’ve worked in retail long enough to realize that the response to anything they don’t want to hear is the other pharmacist does it for me.

 

[CynicalIntern]

FWIW, there's actually a lot of plans that will let you do prior authorizations as a pharmacist. Now, the lack of clinical information that they give you is a different issue entirely.

I'm pretty sure you're in specialty and not traditional retail. What a lot of specialty pharmacies do is get the paperwork, fill out the clinicals, and then send it to the doctors office for review and final signature. If the office is actually not giving you clinicals, then that's a different issue entirely.

 

[Chrissystone]

FWIW, there's actually a lot of plans that will let you do prior authorizations as a pharmacist. Now, the lack of clinical information that they give you is a different issue entirely.

I'm pretty sure you're in specialty and not traditional retail. What a lot of specialty pharmacies do is get the paperwork, fill out the clinicals, and then send it to the doctors office for review and final signature. If the office is actually not giving you clinicals, then that's a different issue entirely.

I work in a hybrid specialty slash normal brick and mortar retail pharmacy. I spend half the day as pharmacist in each section. My issue with these doctor offices is actually not related to the specialty medications. It's normal physician offices asking me to do prior authorization from testosterone to skelaxin to janumet to pennsaid solutions. Losing "business" because I won't do the whole prior authorization for them is annoying especially when the office isn't giving me any information to work with. Icd10 code? What meds have the patient tried?

 

[BidingMyTime]

Eh, if the doctor's office is being that stupid about it, I would just wait a couple of days, and then tell them the PA was denied, so they will have to change the medicine. I have never heard of a pharmacy filling out the PA form for the doctor (I mean maybe, if the doctor had faxed over the pt's chart so the pharmacy could fill it out.) I'm pretty sure you would be opening yourself up to chargebacks, if you make stuff up. Even criminal charges, if you make stuff up for a government payer.

 

[Chrissystone]

Eh, if the doctor's office is being that stupid about it, I would just wait a couple of days, and then tell them the PA was denied, so they will have to change the medicine. I have never heard of a pharmacy filling out the PA form for the doctor (I mean maybe, if the doctor had faxed over the pt's chart so the pharmacy could fill it out.) I'm pretty sure you would be opening yourself up to chargebacks, if you make stuff up. Even criminal charges, if you make stuff up for a government payer.

I'm not into losing my license by making stuff up. I'm completely fine filling out information if they provide it.

 

[Sine Cura]

We just tell people what's covered so there is always the option to just change it or if they have to justify versus the formulary option at least they know what it is.

As for making stuff up we just use come up with a reasonable ICD-10 off Google for California Medi-Cal treatment authorization requests (TARs) if it's routine non-psych maintenance meds like lisinopril or furosemide but those are usually for TARs to have stuff covered beyond 6 Rx per calendar month. When it comes to psych meds the pharmacy is put in the position of having to submit TARs with no access to charts or other clinical info

 

[CynicalIntern]

I work in a hybrid specialty slash normal brick and mortar retail pharmacy. I spend half the day as pharmacist in each section. My issue with these doctor offices is actually not related to the specialty medications. It's normal physician offices asking me to do prior authorization from testosterone to skelaxin to janumet to pennsaid solutions. Losing "business" because I won't do the whole prior authorization for them is annoying especially when the office isn't giving me any information to work with. Icd10 code? What meds have the patient tried?

I would laugh so hard if someone got pissy because I wouldn't help with a PA for Pennsaid solution.

So most likely what is happening is 1 of 2 things:
1) The rep is going there promising that it's going to be $0 no questions asked, who care about silly things like medicare/medicaid causing there to be issues with teh coupon
2) The office of the FP (because of course it's family practice) hears that you help with PAs for something from the Repatha rep (I'm going to assume it's Repatha or Praluent, because they love to do that ****) and don't comprehend the difference between "specialty drugs that you care about" and "stupid **** that you don't care about" and only hear "the pharmacy does...." and "prior authorizations" and gets mad when they hear something other than what you're telling them.

Encourage them to go elsewhere. Give them the phone number of your biggest competitor to make it their problem. I'll go above and beyond for some drugs to make sure I help the office get them covered - but there are no circumstances that I would even WANT for Pennsaid to be covered, much less try to help facilitate it.

 

[Chrissystone]

I would laugh so hard if someone got pissy because I wouldn't help with a PA for Pennsaid solution.

So most likely what is happening is 1 of 2 things:
1) The rep is going there promising that it's going to be $0 no questions asked, who care about silly things like medicare/medicaid causing there to be issues with teh coupon
2) The office of the FP (because of course it's family practice) hears that you help with PAs for something from the Repatha rep (I'm going to assume it's Repatha or Praluent, because they love to do that ****) and don't comprehend the difference between "specialty drugs that you care about" and "stupid **** that you don't care about" and only hear "the pharmacy does...." and "prior authorizations" and gets mad when they hear something other than what you're telling them.

Encourage them to go elsewhere. Give them the phone number of your biggest competitor to make it their problem. I'll go above and beyond for some drugs to make sure I help the office get them covered - but there are no circumstances that I would even WANT for Pennsaid to be covered, much less try to help facilitate it.

I truly despise that drug company. I do not understand vimovo, duexis, or pennsaid and why it costs over $2000 for those drugs knowing what they are made of.

 

[rx1983]

I was allowed to do a PA once by an insurance company when the doctor was out having surgery, other than that never. I can’t imagine the trouble that could get you into if it’s caught during an audit.

 

[Apotheker2015]

Something the owner of my pharmacy is adamant about is not doing prior authorizations for doctors. We can fill out some information should we have the information but he is very serious about not faxing anything to the insurance companies from our fax machine or forging information on the prior authorization forms. If a doctor's office wants us to fill out the demographic information on the prior authorization forms, we will and then fax it to the doctor's office to complete the clinical information.

I've been told from several doctors offices that other pharmacies do it for them, they will call the PBM PA line and answer as if they were calling from the doctor's office or even sign the forms for the doctors. I have no idea how this is legal and when I tell the doctor that they can use the other pharmacy to fill for them, they start yelling at me about how they will never send scripts to my pharmacy again. (Pretty sure, directing scripts for patients is illegal too..) Whenever I call the doctor's office to let them know that there needs to be a prior authorization for the medication, their attitude changes like 180 degrees. The receptionist puts me on hold for over 15 minutes or deliberately hangs up.

So how exactly does a pharmacy do prior authorizations for doctors? Is there a form that the doctors sign to authorize the pharmacy to do this on their behalf? I am looking for some insight as my understanding may be outdated.

If you go to the covermymeds website and take a look at how many pharmacists they have on staff -zero-, you will quickly realize they have no concept of how little time is available to accomplish tasks in retail pharmacy. Their system even allows patients to submit a PA request which adds a layer of confusion to the whole process because then the patient does not understand why they still have to wait for the prescriber to document why the agent is medically necessary.
100% no-go on my part. They can fill out their own PAs. We don't have time for all of that.