As part of EZ Scripts Pharmacy, being what a workers’ compensation pharmacy should be, we will continue onto another series of breakdowns of topics related to workers’ compensation.
Workers’ compensation is difficult for all stakeholders, and our goal is simple, to demystify elements of a complex industry.
For our seventh installment, we will address the Best Practices for Providers and Claims Professionals.
This series will cover the following topics:
- What Is Prior Authorization in Workers’ Compensation? https://www.ezrxmeds.com/what-is-prior-authorization/
- When Is Prior Authorization Required? https://www.ezrxmeds.com/when-is-prior-authorization-required-in-workers-compensation/
- The Prior Authorization Process: Step by Step. https://www.ezrxmeds.com/the-prior-authorization-process-step-by-step/
- Why Prior Authorization Requests Get Denied. https://www.ezrxmeds.com/why-prior-authorization-requests-get-denied/
- What Happens After a Prior Authorization Is Denied? https://www.ezrxmeds.com/what-happens-after-a-prior-authorization-is-denied/
- How Prior Authorization Affects Injured Workers. https://www.ezrxmeds.com/how-prior-authorization-affects-injured-workers/
- Best Practices for Providers and Claims Professionals.
- The Future of Prior Authorization in Workers’ Compensation.
Best Practices for Providers and Claims Professionals.
Prescription medications can play an important role in helping injured workers manage symptoms and recover from workplace injuries. However, when a medication requires prior authorization, the approval process can sometimes create additional steps for everyone involved.
Healthcare providers, claims professionals, and pharmacies all have an important role in keeping the medication process moving. When each party communicates effectively and provides the information needed for review, injured workers may be less likely to experience unnecessary prescription delays.
Here are several best practices providers and claims professionals can follow when handling medication prior authorizations in workers’ comp.
Submit Complete Medication Requests
One of the most important steps in the prior authorization process is making sure the request contains the information needed for review.
Providers should clearly document the injured worker’s diagnosis, relevant medical history, symptoms, and reason for prescribing the medication. Information about previous medications or treatments may also be important when explaining why a particular medication is appropriate. Incomplete requests can lead to additional questions and may delay the review process.
Before submitting a medication authorization request, providers should make sure the relevant clinical information is included and easy for the reviewer to understand.
Clearly Explain Medical Necessity
A medication request should provide a clear explanation of why the medication is being prescribed for the workplace injury. Simply listing a diagnosis and medication may not provide enough context. Providers should explain how the medication relates to the worker’s condition and why it is appropriate as part of the treatment plan.
Clear clinical documentation can help claims professionals and reviewers better understand the request and determine whether additional information is needed.
Use Applicable Workers’ Comp Medication Guidelines
Medication authorization decisions may be based on state specific workers’ comp requirements, treatment guidelines, formularies, and other applicable rules.
Providers should be familiar with the guidelines that apply to the injured worker’s claim. Understanding these requirements can help providers select appropriate medications and provide the supporting information needed for authorization.
Claims professionals should also make sure medication requests are reviewed according to the rules and guidelines applicable to the claim.
Respond Quickly to Requests for Additional Information
Sometimes a medication request requires clarification or additional documentation before a decision can be made.
When additional information is requested, timely communication can help prevent unnecessary delays. Providers should respond as quickly as practical when documentation or clarification is needed. Claims professionals can also help by clearly communicating what information is missing rather than sending incomplete or unclear requests back to the provider.
A straightforward exchange of information can make the authorization process easier for everyone involved.
Communicate With the Pharmacy
The pharmacy is often the first place an injured worker discovers that a medication requires authorization. When a prescription cannot be processed, the pharmacy may need to communicate with the provider or claims professional to determine what is needed.
Providers and claims professionals should maintain clear communication with the pharmacy when questions arise about a prescription. Confirming the status of an authorization request can help prevent the injured worker from being left without information about when the medication may become available.
Keep Injured Workers Informed
Injured workers should not have to guess what is happening with their medication.
When a prescription is delayed because authorization is pending, providers and claims professionals should communicate clearly about the status of the request whenever possible. Explaining whether the request is pending, approved, denied, or awaiting additional information can help the injured worker understand the situation and know what to expect.
Good communication can also reduce unnecessary calls and confusion between the worker, provider, pharmacy, and claims professional.
Track Authorization Requests
Keeping accurate records of medication authorization requests can help providers and claims professionals identify delays and follow up when necessary.
Important information may include the date the request was submitted, the medication requested, the status of the request, any additional information requested, and the date a decision was received.
An organized process makes it easier to determine what has already been completed and what still needs attention.
Avoid Unnecessary Delays
Prior authorization is designed to evaluate whether a medication is appropriate and medically necessary, but avoidable administrative issues should not make the process more difficult.
Providers can help by submitting complete requests the first time. Claims professionals can help by reviewing requests promptly and communicating clearly when additional information is needed. Pharmacies can also help identify problems early when a prescription cannot be processed.
When everyone involved understands their role, the process can become more efficient.
Have a Process for Denied Medication Requests
Not every medication request will be approved as submitted. When a request is denied, providers and claims professionals should carefully review the reason for the decision. Depending on the applicable workers’ comp rules, additional documentation, reconsideration, or another review process may be available.
Providers should make sure they understand the reason for a denial before deciding what to do next. Claims professionals should also communicate the decision and relevant next steps clearly.
A structured process for handling medication denials can help prevent confusion and keep the injured worker informed.
Consider the Impact on the Injured Worker
Every authorization request represents a medication that an injured worker may be waiting to receive.
For the provider, claims professional, and pharmacy, a prior authorization may be one administrative task among many. For the injured worker, however, the medication may be an important part of managing their workplace injury.
Keeping the injured worker at the center of the process can encourage better communication, faster follow up, and greater attention to potential delays.
How EZ Scripts Pharmacy Can Help
Managing workers’ comp prescriptions can involve communication between multiple parties. EZ Scripts Pharmacy can help simplify the prescription process for injured workers, providers, and claims professionals by making it easier to manage workers’ comp medication needs.
By using EZ Scripts Pharmacy, injured workers can simplify the prescription process, reduce potential delays, and get the medications they need to support their recovery with greater convenience and peace of mind.
Making Workers’ Comp Medication Authorization More Efficient
Prior authorization does not have to be a source of unnecessary frustration. Providers can help by submitting complete clinical information and clearly documenting medical necessity. Claims professionals can help by reviewing requests efficiently and communicating what is needed. Pharmacies can help by identifying authorization issues and keeping the appropriate parties informed.
Most importantly, everyone involved should remember that the ultimate goal is helping the injured worker receive appropriate medication as efficiently as possible.
A clear, organized, and collaborative approach to medication prior authorization can help reduce administrative problems while supporting a smoother workers’ comp prescription experience.
At EZ Scripts Pharmacy, we are here to help all injured workers that we can.
Call 443.290.6337 or visit to https://www.ezrxmeds.com/sign-up-today-clients-patients-referrals/ to enroll today.