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 fourth installment, we will address why Prior Authorization Requests Get Denied.
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.
- What Happens After a Prior Authorization Is Denied?
- How Prior Authorization Affects Injured Workers.
- Best Practices for Providers and Claims Professionals.
- The Future of Prior Authorization in Workers’ Compensation.
Why Prior Authorization Requests Get Denied
When you are recovering from a workplace injury, getting the medication prescribed by your healthcare provider should be a straightforward part of your treatment. However, some workers’ compensation medications require prior authorization before the workers’ compensation payer will approve coverage.
A prior authorization denial can be frustrating, especially when you are experiencing pain or other symptoms and need your medication to continue treatment. In many cases, a denial does not mean that the medication is inappropriate. It may mean that the request did not meet specific workers’ compensation requirements, additional information was needed, or the medication did not meet the applicable treatment guidelines.
Understanding why workers’ compensation prior authorizations get denied can help injured workers’ and healthcare providers know what to look for and what steps may be available next.
1. The Medication Does Not Meet Treatment Guidelines
One of the most common reasons a workers’ compensation medication request may be denied is that the requested treatment does not meet the applicable treatment guidelines.
Workers’ compensation systems may use evidence based treatment guidelines or medication formularies when reviewing treatment requests. These guidelines can address which medications are recommended for particular injuries and circumstances.
If the requested medication falls outside those guidelines, the provider may need to provide additional clinical information explaining why the medication is appropriate for the injured worker. Treatment guidelines are not identical in every state, so the requirements for one workers’ compensation claim may differ from another.
2. Medical Necessity Has Not Been Established
A medication may also be denied when the documentation does not establish medical necessity. The healthcare provider may believe that a particular medication is necessary, but the utilization review process generally requires supporting clinical information.
The documentation may need to explain the diagnosis, the work related injury, the patient’s treatment history, the purpose of the medication, and the expected benefit.
3. The Medication Is Not Sufficiently Connected to the Work Injury
Workers’ compensation coverage generally relates to treatment for an accepted workplace injury or condition. If the requested medication appears to be treating a condition that is not part of the accepted claim, the payer may question whether the medication should be covered under workers’ compensation.
This can happen when a patient has multiple medical conditions or when the connection between the medication and the workplace injury is not clearly explained in the submitted documentation. Clear documentation from the healthcare provider can help establish how the medication relates to the workers’ compensation injury.
4. The Prior Authorization Request Is Missing Information
A prior authorization request can be delayed or denied when the reviewing organization does not receive enough information to evaluate the medication. Missing information may include medical records, diagnosis information, treatment history, medication history, clinical findings, or an explanation of why the requested medication is needed.
A complete request gives the reviewer the information needed to make a decision.
5. The Provider Did Not Submit the Required Documentation
Even when a medication is medically appropriate, the authorization process depends on the information submitted with the request. If required documentation is missing, the reviewer may not have enough information to approve the medication.
This is one reason communication between the healthcare provider, pharmacy, and workers’ compensation payer is so important.
6. The Medication Requires Additional Authorization
Some medications are subject to specific workers’ compensation authorization requirements. A medication may require additional review because of its classification, cost, dosage, duration of treatment, or position within a workers’ compensation drug formulary. The exact requirements depend on the applicable state system.
This means a prescription that can be processed routinely in one situation may require additional authorization in another.
7. The Requested Medication Does Not Meet Formulary Requirements
Workers’ compensation medication formularies can influence whether a prescription requires authorization and whether it is eligible for coverage. A formulary may identify medications that can be used without prior authorization and medications that require additional review.
When a requested medication falls into a category requiring authorization, the provider may need to submit information supporting its use. Formulary requirements can also change, which is why it is important for providers and pharmacies to use current workers’ compensation requirements when processing medication requests.
8. Another Medication May Be Recommended
A prior authorization can sometimes be denied because the requested medication does not meet the payer’s preferred treatment requirements. The payer may determine that another medication is more appropriate under the applicable treatment guidelines or formulary.
This does not necessarily mean that the prescribed medication is unsafe or ineffective. It may simply mean that the workers’ compensation program requires additional justification before covering it. The healthcare provider can review the decision and determine whether an alternative medication is appropriate or whether additional documentation should be submitted.
9. There Is Not Enough Evidence of Treatment Benefit
For some ongoing medications, the reviewer may look for evidence that the treatment is providing a meaningful benefit. Documentation may include information about symptom improvement, functional improvement, objective findings, or the patient’s response to treatment.
If the medical records do not explain how the medication is helping the injured worker, the reviewer may determine that continued treatment has not been adequately supported. This is particularly important when a medication has been prescribed for an extended period.
10. The Request Does Not Follow the Applicable Workers’ Compensation Process
Workers’ compensation authorization is not handled exactly like a typical health insurance prescription claim. Each state has its own workers’ compensation laws and procedures. There may also be specific requirements established by the insurance carrier or claims administrator.
A request can encounter problems when the required process is not followed, the wrong information is submitted, or the request is sent to the wrong entity.
11. The Workers’ Compensation Claim Does Not Cover the Requested Condition
Another potential reason for denial is a dispute about whether the medication is related to the workers’ compensation claim. A workers’ compensation payer may determine that the requested medication is associated with a condition that is not accepted as part of the claim.
This is different from a medical necessity denial. In some circumstances, the issue is whether the workers’ compensation claim is responsible for the treatment at all. The appropriate response depends on the facts of the claim and the workers’ compensation rules in the applicable state.
The Role of the Pharmacy
The pharmacy is often the first place where a prior authorization requirement becomes visible. When the prescription is processed, the pharmacy may receive a response indicating that authorization is required or that the claim cannot be processed.
The pharmacy can communicate the issue to the appropriate parties and help identify what is needed to move the prescription forward. However, clinical authorization decisions generally require information from the healthcare provider and review by the workers’ compensation payer or utilization review organization.
How EZ Scripts Pharmacy Can Help
Workers’ compensation prescriptions can involve additional steps that are not part of a typical prescription claim. Prior authorization requirements, claim information, treatment guidelines, and communication between healthcare providers and workers’ compensation payers can all affect how quickly a medication is approved.
EZ Scripts Pharmacy understands the importance of making the prescription process as convenient as possible for injured workers. When a medication requires prior authorization, our goal is to help facilitate the prescription process while working with the appropriate parties to address authorization and processing requirements. Call 443.290.6337 or visit to https://www.ezrxmeds.com/sign-up-today-clients-patients-referrals/ to enroll today.