Ask a pharmacy team what makes prior authorizations painful and you will hear about forms. Too many of them, all different, always asking for something the prescriber’s office has to supply.
The forms are annoying. They are not the expensive part.
A prior authorization is a case. It lives for days across at least three organisations, and almost nothing in a pharmacy is built to hold a case. It lives in a person’s head, a sticky note, a will call bag and a text thread. That costs money in three places.
Nobody owns it
A rejection comes back at the counter. A technician starts something: a call to the prescriber, a fax, a note in the patient’s profile. Then the queue moves and the shift ends.
The next person to touch that patient cannot tell what stage the case reached, whether the office was already called, who they spoke to, or what was asked for. So the work is redone or dropped, and the pharmacy cannot tell which without doing it again. The patient calls on day four and the honest answer is that nobody knows.
Nobody sees the clock
Every payer has turnaround expectations, and appeal windows close. A case legitimately waiting on the plan looks exactly like a case forgotten on day one. No screen ages a pending authorization, so nothing escalates until the patient escalates it.
The result is abandonment. The prescription sits, the patient goes without, and the fill is eventually reversed. That loss gets recorded, if it gets recorded at all, as an unrelated reversal rather than as an authorization that timed out.
Nothing is learned
The same plan asks for the same clinical evidence on the same drug class, over and over. Step therapy documentation. A recorded trial and failure. A specific lab value.
A pharmacy that ran two hundred authorizations last year is sitting on a detailed map of what each payer actually wants on the first submission. Almost none of it is written down. So the two hundredth case gets fought exactly as hard as the first.
What good looks like
Use the electronic rails properly. Electronic prior authorization beats fax and the infrastructure already exists. Surescripts operates an electronic prior authorization service built to “streamline the prescription authorization process” and help patients get medication “without unnecessary delays”. CoverMyMeds is the other name a prescriber’s office is most likely to already have open. If a request can go electronically it should, and any tool that quietly reverts to fax has added a day for no reason.
Give the case an owner and a state. Not a note. A record with a status, an assignee and a last action, visible to whoever is standing at the counter when the patient walks in. The highest value change here costs nothing in software: one named person reviews every open authorization every morning.
Make the clock visible. Age every open case in days, sorted descending. Anything past the payer’s stated turnaround gets a follow up that day. Anything approaching an appeal deadline gets escalated before the window closes.
Write down what each payer wanted. One line per resolved case, keyed to plan and drug class. Within a year it becomes the most valuable internal document in the pharmacy, because it turns a repeated argument into a checklist you complete before the first submission.
Close the loop on outcome. Approved, denied, appealed, abandoned, and if abandoned, at what stage. Without that you cannot tell whether your authorization process is improving, or which payers are worth pushing on.
The ePA networks solved their half of this well. The other half belongs to the pharmacy: an authorization is a small, slow, multi party workflow, and it needs to be run like one.
Attergo Authorizations drafts the request from the record you already hold, keeps every open case in one queue with its age and its payer, and surfaces the renewal before the therapy lapses. Book a demo and we will run it against your own rejections.