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Ambulatory Medication Prior Authorization Coordinator

Site Name

UW Health Enterprise, Madison, WI

Primary Intended Outcomes

  1. Improve patient care fragmentation by providing internal prior authorization (PA) services and care for the entire patient (fill all medications, not solely specialty medications);
  2. Improve visibility of internal pharmacy services to patients and providers within our organization;
  3. Shift workload to an appropriate skill mix to improve nursing satisfaction and allow more time for direct patient care related activities.

Site Description

UW Health Enterprise consists of a University Hospital (648 beds) Level 1 adult and pediatric trauma center and regional referral center, an 87 bed children's hospital, 56 bed community based health and wellness facility and a 50 bed rehabilitation facility. The pharmacy enterprise consists of 365 FTE which include 125 pharmacists, 178 pharmacy technicians and support staff, 25 pharmacy residents and 37 members on the management team. There are 7.3 FTE of pharmacy technician dedicated to the Ambulatory Medication Prior Authorization Coordinator role and are staffed Monday through Friday from 7:30 a.m. until 4:00 p.m.

Advanced Role Description

  • Provide clinic-based prior authorization support for specialty medications including Pediatric Specialty practices since 2006 with subsequent expansion to non-oncology practices in 2007;
  • Provide benefits investigations for specialty medications including locating patient insurance, submitting test claims and executing prior authorizations on behalf of prescribers for 28 specialty clinics;
  • Prospectively complete re-authorization of expiring prior authorizations for patients that will be continuing therapy;
  • Identify co-pay assistance for specialty medications including manufacturer co-pay cards or foundation assistance;
  • Promote UW Specialty Pharmacy Services to clinic patients that we service.

Tools and Resources

Software and programs, desktop computer with dual extended screens, prescription scanner, pager, direct (dedicated) phone line, fax machine, laser printer.

Revenue and Expense Parameters & Outcome Measures

UW Health utilizes financial modeling and data to estimate the financial opportunity in order to target specific clinics for service implementation. This is a service that should critically evaluate the patient care and workload implications of the service, in addition to financial opportunity. Focused incremental program expansion aligned with new drug therapy approvals and predicted drug access issues help grow the program to cover additional clinics and add FTE needed for this growth. Building AMPAC accountability and demonstrating financial competence coupled with testimonials from front-line staff to accompany financial projections supports FTE growth. Metrics include PA overall volumes, estimated patient financial and time savings, time to patient medication initiation, staff satisfaction, and financial performance versus forecast.

Training and/or Education Requirements

  • Development of policy and procedures associated with workflow processes and signatory authority from clinics;
  • Development and optimization of our electronic medical record vendor to support the work of this group and evaluation of electronic prior authorization systems;
  • Development of training materials focused on disease state education for AMPAC staff;
  • Many of the documents have been developed as part of pharmacy student rotations and/or residency projects;
  • Regular evaluation of materials, updates, and ensuring that the hiring manager is directly involved in the training process of new staff allows for real-time evaluation of the pertinence of the training materials and what needs to be updated;
  • Staff are also highly engaged in the role and manage the updating and development of materials independently based on their experience with training new staff.

Lessons Learned

  • UW Health AMPAC staff experience regular, meaningful impacts on patient care;
  • The selection of staff in this role is critical, they need to be clinic-facing (but not necessarily based in the clinic), and the implementation and roll-out of this service at the clinic level is critical;
  • Staff is better served working in a group rather than remotely within the clinic in order to build efficiencies and increase accountability
  • Scope creep beyond targeted PA services provided to clinic staff must be avoided;
  • After implementation, staff needs to efficiently manage clinic relationships and prevent confusion raised by direct-to-clinic vendor/specialty pharmacy marketing;
  • Establish and maintain a relationship with support staff (RNs, CMAs, NPs) instead of approaching the prescribers directly;
  • Maintain transparency by establishing a clear workflow that will make all steps of the prior authorization process visible to other PA and clinic staff;
  • Structure the implementation by starting small and branching out to the more difficult disease states once a reliable workflow has been established;
  • Be flexible, as the process may need to change for a specific clinic to meet their needs;
  • Realized benefits — Improved patient outcomes, improved re-authorizations of prior authorizations, streamlined prior authorizations approvals; increased financial assistance; improved nursing satisfaction;
  • Future opportunities — Continue to expand into more UW Health clinics and eventually service clinics that are a part of our regional affiliation.

Visit the Pharmacy Society of Wisconsin website for more information and to learn about their pharmacy advancement initiatives.