4 Common Medication-Related Insurance Rejections Providers Should Understand
Key takeaways:
The most common type of medication-related insurance rejection providers face is a prior authorization (PA). Insurance companies (payers) use PAs to increase prescribing of medications on their preferred formulary.
“Refill too soon” and out-of-network rejections are also common. A “refill too soon” rejection can sometimes be overridden. But, an out-of-network rejection requires a prescription to be sent to the patient’s in-network pharmacy.
Drug utilization review (DUR) rejections are clinical alerts where the payer has a clinical concern with the prescription, based on claims data. It’s critical for providers to handle these rejections directly.
Insurance rejections are a common part of daily practice for pharmacists and healthcare providers. Rejections help insurance companies (payers) control costs. But they can add a significant administrative burden for medical offices.
Understanding insurance rejections can help provider offices improve workflow and communication. This can also save staff time and ensure people in their care get the medications they need.
In this article, we’ll look at the most common types of medication-related insurance rejections and discuss ways providers and pharmacists can handle them.
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1. Prior authorizations
Prior authorizations (PAs) are one of the most common kinds of rejections. A PA helps payers control cost by increasing use of medications on their preferred formulary.
The fastest way to handle PAs is to use an electronic PA (e-PA) service. The e-PA process looks like this:
The prescription is sent to the pharmacy, and the pharmacy receives a PA rejection from the insurance company.
The pharmacy sends a PA request to the provider’s office. This request already includes most of the patient’s basic information, including the medication being requested.
The office staff logs into the e-PA account and completes the request, which includes answering clinical questions and sometimes attaching chart notes.
Insurance companies sometimes deny prior authorizations. They often will not approve a non-formulary product unless:
A person has already tried their plan’s preferred products
A person has an intolerance or contraindication to the preferred products
A provider demonstrates that switching medications is essential to treatment success
If your office receives a denial, there are two actions you may be able to take:
Peer-to-peer review: With a peer-to-peer review, a healthcare professional working for the insurance company speaks with the provider directly and decides if the denial should be overridden. You’ll often need an appointment for a peer-to-peer review.
Appeal: An appeal is time-consuming, because it involves writing a letter to the insurance company explaining the person’s situation and why they’re unable to use products on the formulary.
The letter included with the PA denial will provide contact information for both appeals and peer-to-peer reviews.
Embedded pharmacists can also help with the PA process. These are pharmacists who work inside a medical office rather than in a pharmacy.
In summary
PAs are a process insurance companies use to control their costs. Medical offices are responsible for responding to requests and denials. But embedded pharmacists and technicians, who are becoming more commonplace, can be a great resource for handling these.
2. Refill too soon
Each time a prescription is filled, a pharmacy’s staff submits a record to the insurance company with both the quantity filled and the length of time the prescription is supposed to last.
Most payers only approve refills when the medication should be getting low, to prevent them from paying for too much medication. For example, an insurer may pay for a refill on a 30-day supply of medication only after 23 days have passed since the last prescription was filled. Filling it before this point can trigger a “refill too soon” rejection.
Sometimes you can obtain a “refill too soon override” for this rejection. Two common overrides are:
Vacation override: If the person is going on vacation and would run out of medication before getting back, they may be able to get a refill early. But this is often limited to one or two overrides per year.
Medication synchronization: Medication synchronization is an adherence service where the pharmacy aligns a person’s refills to be filled on the same day each month. The pharmacy has to fill a small quantity of medication to align them. Some insurers will pay for medication synchronization. But it’s possible for these small fills to initially trigger a “refill too soon” rejection.
In summary
“Refill too soon” rejections happen because a person is trying to get their medication before the payer thinks it’s due. In some cases, the pharmacist can obtain a “refill too soon override” for these rejections.
3. Out-of-network
Payers often have preferred pharmacy networks, especially for specialty or high-cost medications. They may choose one or two in-network mail order pharmacies for these medications. Insurance changes, which commonly happen at the beginning of the year or with job changes, can affect a person’s in-network pharmacies.
If you get an out-of-network pharmacy rejection, you’ll likely need to send the prescription to an in-network pharmacy.
This is another case in which an embedded pharmacist can help. In some cases, a pharmacy may be able to transfer the prescription. But, that can be time-consuming, especially if it requires calling a mail-order pharmacy.
In summary
An out-of-network rejection happens when a pharmacy is not in an insurance company’s preferred network. In this case, the out-of-network pharmacy may need to transfer the prescription to the in-network pharmacy. The provider may also need to send a new prescription to that pharmacy.
4. Drug utilization review rejections
Out of all of the medication-related rejections an office receives, a drug utilization review (DUR) rejection is the one type the provider should personally look at. These rejections are clinical alerts from payers, based on their claims history.
DUR rejections designed to help keep patients safe. They happen when payers notice medication overuse, interactions, or other safety issues. It’s best for a provider to address these directly. Office staff shouldn’t be overriding them on their own.
Examples of DUR rejections include:
Prescribing a benzodiazepine with an opioid
Prescribing a high dose of an opioid
Prescribing a medication for an older adult that can raise the risk of falls
A pharmacist can enter codes to override these rejections. However, some require the pharmacist to attest to speaking with and getting approval from the prescriber. The pharmacist will typically call the office about DUR rejections. But they may override them if they've spoken with a provider about it before.
In summary
DUR rejections are clinical warnings insurance companies use to keep patients safe. Pharmacists override the majority of them, but there are times they may call the prescriber’s office. In these cases, it’s best for the provider to directly address the concern. Don’t allow office staff to override DUR rejections.
The bottom line
There are several types of insurance rejections that can happen at the pharmacy. But not all rejections can be handled by the pharmacist. Understanding the most common types of rejections and how to handle them can help you and your staff save time and ensure your patients receive their medications.
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References
Academy of Managed Care Pharmacy. (2019). Drug utilization review.
Agency for Healthcare Research and Quality. (2022). United States Health Information Knowledgebase.
American Medical Association. (2017). Reduce practice burdens with electronic prior authorization.
American Medical Association. (2023). Prior authorization practice resources.
Robeznieks, A. (2021). How to make peer-to-peer prior authorization talks more effective. American Medical Association.
