ReachMD

In the last several years, the market for biologics has increased. The insurance authorization process has become more burdensome for the clinic to access certain biologics for patients. Now is the time to ensure your office is set up for success with the assistance of a knowledgeable biologic coordinator (sometimes called an access coordinator or prior authorization specialist).

After working in the biologic coordinator role for more than 9 years, I have seen first-hand how often insurance requirements change. The overwhelming frustrations of getting access for patients and providers was one of the reasons I made it my goal to figure out the best way to streamline the process and help offices receive the support they need. It all starts with education—not only for your medical staff, but for your patients as well. Equipping your team with the right information and tools will allow them to best educate your patients.

My number one priority is to gain approval for the biologic agent or specialty medication that my provider has prescribed. Insurance makes that difficult, but with the right tools and knowledge, you can identify and learn to utilize your resources.

Charting for Success

Charting is always a hot topic when it comes to access. It’s important to know that each disease state will have different requirements. Additionally, insurance formularies change often, especially and when new drugs come to market. Most plans are going to be looking for a scoring tool, a tried-and-failed history, and clinical rationale.

Here are some chronic dermatological conditions treated with specialty medications, accompanied by possible scoring tools required by insurance.

• Psoriasis - BSA, PGA, IGA, DLQI,
• Atopic Dermatitis - BSA, EASI, AD-IGA,DLQI
• Alopecia - SALT, AA-IGA
• Hidradenitis Supperativa - Hurley Stage, DLQI
• Vitiligo - AFFECTED AREAS/BSA, DLQI
• Prurigo Nodularis - NUMERIC ITCH SCORE, 20+ LESIONS, DLQI

There could be other information that insurance companies require, such as if the patient has tried/failed methotrexate or light therapy. This is a good time to be proactive and document why the patient can or cannot take the requested step therapy. Documentation reduces issues and hiccups when it comes to access.

Reauthorization

When it comes to reauthorization time, it is important that the follow-up visit corresponds properly with the original note. Small things, such as indicating that a patient is not yet at treatment goal can, may result in a denial. We want to ensure that the patient is able to continue therapy even if they are not quite at treatment goal. The best way to do that is to note the improvement, but also note that the patient needs to continue therapy to maintain clinical response. Being as detailed as possible with the documentation really helps to eliminate a lot of the miscommunication and can position a prior authorization for the best outcome.

We can work with our doctors, NPs, and PAs to get as much detail as possible. It’s always about the details. Insurance companies can change formularies and step therapy requirements very often, so it’s important to stay up to date. Don’t worry—that’s what your Biologic Coordinator is there to do!