Get prior authorization for a drug

Market: Family Health Managers managing their family's healthcare needs

Scenario: Patient navigates the burdensome process of obtaining prior authorization for a medication. She manages doctor communication, tracks insurance approvals, coordinates with pharmacies, and resolves denials, all while balancing her family's health needs and a demanding schedule.

Average Difficulty: Intense (30%+ Range).

31 Outcomes 30% to 62% Difficulty.

Research Insights

The research highlights significant frustration around delays, lack of clarity, and communication gaps in obtaining prior authorizations. Family health managers struggle with doctor-pharmacy-insurance coordination, unclear denial reasons, and ensuring timely medication access. Family health managers desire streamlined, transparent processes that reduce delays, clarify approval steps, and improve communication between involved parties.

Job Steps

Job steps are the current sequential steps that the market goes through to accomplish this job.

1. Get a prescription from my doctor

2. Find out the pharmacy needs approval from insurance

3. Make sure my insurance covers the medicine

4. Wait to hear back from insurance

5. Follow instructions from insurance

6. Keep track of approvals and renew them if needed

Themes Identified

  • Communication and Coordination: Increase the ease of contacting the doctor for prescriptions. Increase the clarity of pharmacy notifications about prior authorization requirements. Increase the consistency of approval communications between doctors, pharmacies, and insurance. Decrease the difficulty of coordinating with multiple pharmacies for prescriptions.
  • Transparency and Clarity: Increase the clarity of insurance coverage policies. Decrease the difficulty of knowing which medications require prior authorization. Increase the ease of understanding approval or denial notices. Increase the clarity of steps needed for recurring medication refills.
  • Timeliness and Efficiency: Decrease the time it takes to get a prescription approved when insurance requires prior authorization. Decrease the time it takes to identify prior authorization requirements. Decrease the frequency of delays caused by missing forms. Decrease the time it takes for pharmacies to notify about rejections.

Recommendations

  • Automated Prior Authorization Tools: Develop tools to automatically check if a prescription requires prior authorization and notify all parties (doctor, pharmacy, patient) in real time.
  • Clear Status Tracking: Implement an easy-to-use status dashboard where patients can monitor the progress of approvals and see next steps clearly.
  • Integrated Communication Platform: Create a unified platform for doctors, pharmacies, and insurance providers to exchange information and resolve approval gaps quickly.
  • Proactive Notifications: Provide patients with automated alerts for denials, updates, and refills to prevent delays.
  • Simplified Denial Resolution: Offer guided workflows for patients to understand and appeal denials quickly, reducing confusion and stress.

Cautions

  • Avoid Overloading Patients with Complex Language: Ensure all communications, such as denial notices, are simple, clear, and actionable.
  • Do Not Rely Solely on Manual Processes: Manual checks and paper forms slow approvals; prioritize digitization.
  • Avoid Fragmented Communication Channels: Ensure updates and next steps are shared in one location, not across multiple disconnected systems.
  • Don't Neglect Edge Cases: Address issues like emergency approvals, rare medications, and multi-pharmacy coordination proactively.
  • Avoid Reactive Support Only: Build proactive notifications to prevent delays rather than relying on patient-initiated follow-ups.

Outcomes

The difficulty percent below are the percent of the market that finds this outcome difficult to achieve.

Difficulty Outcome
62% Decrease the difficulty of planning for ongoing medication refills
60% Increase the clarity of doctor communication about prior authorization
60% Increase the clarity of steps needed for recurring medication refills
51% Increase the ease of contacting the doctor for prescriptions
51% Increase the consistency of refill approvals for chronic conditions
50% Decrease the time it takes for pharmacies to notify about rejections
50% Decrease the time it takes to get forms submitted to insurance
50% Decrease the difficulty of getting emergency approvals for life-saving medications
48% Increase the ease of accessing mail-order pharmacies for rare medications
48% Increase the consistency of insurance approvals for recurring medications
47% Increase the ease of preemptively submitting prior authorization forms
45% Decrease the difficulty of accessing alternate pharmacies for approvals
45% Decrease the time it takes to get emergency medication when approvals are delayed
44% Decrease the cost of emergency medications during approval delays
41% Increase the ease of tracking insurance approval statuses
41% Decrease the difficulty of coordinating with multiple pharmacies for prescriptions
40% Increase the ease of accessing status updates for approvals
40% Decrease the time it takes to identify prior authorization requirements
40% Increase the clarity of insurance requirements for specific medications
40% Increase the ease of understanding approval or denial notices
37% Increase the clarity of insurance coverage policies
36% Increase the consistency of approval communications between doctors, pharmacies, and insurance
36% Decrease the difficulty of understanding insurance denial reasons
35% Decrease the difficulty of knowing which medications require prior authorization
35% Decrease the time it takes for doctors to complete prior authorization forms
35% Decrease the time it takes to resolve communication gaps between parties
35% Decrease the frequency of delays caused by missing forms
33% Increase the clarity of pharmacy notifications about prior authorization requirements
32% Increase the ease of resolving approval denials
30% Decrease the time it takes to get a prescription approved when insurance requires prior authorization
30% Decrease the difficulty of transitioning between insurance plans

Sean Gallivan's ridiculously simple signature. Seriously, it is just an X. Why would I put this online anyway? Do I have no fear?
seangallivan@gmail.com

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