Dealing with prior authorizations compares to navigating a labyrinth—complex, frustrating, and time-consuming. Created to ensure the optimal use of healthcare resources and minimize unnecessary expenses, these authorizations come in two flavors: medical and pharma. What differentiates the two, and why should you care? As the regulatory landscape around interoperability, prior authorizations, and pharmacy benefit managers (PBMs) continues to evolve,  integrated prior authorization software offers a robust solution now and into the future. 

What distinguishes medical prior auth from pharma prior auth? 

Medical prior authorizations pertain to the pre-approval necessary for various healthcare services like surgeries, diagnostic tests, or medical equipment. In addition, certain medications, such as infusion therapies, fall under medical benefits and thus require medical prior authorizations. Before you deliver those services or administer specialized medications to patients, you need the payer to sign off. 

Pharma prior authorizations, on the other hand, focus predominantly on prescription medications that fall under pharmacy benefits. Whether a costly branded drug or a unique treatment, the PBM or payer  must pre-approve its use. What’s more, the patient’s plan type and medication being requested can influence how the prescription is filled once authorized. PBMs may require use of a particular pharmacy—especially for specialty medications—connected with the PBM or use a mail-in pharmacy which can delay access and negatively impact medication adherence. 

Summary of Key Differences

• Scope: Medical authorizations cover a broader range of services, including medical procedures, equipment, and certain medications like infusion therapies. Pharma authorizations deal mainly with medications.
• Approval Entities: For medical authorizations, providers usually interact directly with the payer. In the case of pharma authorizations, the provider or pharmacist may need to interact with a PBM and/or a payer. 
• Clinical Justifications: Both types require clinical evidence, but the specifics differ. Medical procedures often need diagnostic tests and medical history, while pharmaceuticals may require formulary adherence.

However, despite the differences, medical and pharmacy prior authorization have one thing in common: It’s a frustrating, time-consuming process that often fails to deliver promised benefits.  In fact, an AMA provider survey found that: 

• 94% said it led to delays in accessing necessary care
• 80% said it led to patients abandoning treatment
• 89% said it had a negative impact on patient clinical outcomes

Clearly, it’s a challenge that needs solving … and automated prior authorization for pharma and medical benefits can help. 

Prior authorization software for ALL benefits streamlines your workflow

Efficiency

Automating prior authorizations boosts productivity right away by removing a majority of manual data entry. In addition, because the software dynamically pulls in information from patients’ health and benefits information, providers’ clinical documentation, and payers’ plans and policies, your staff doesn’t need to undertake the typical scavenger hunt to determine if prior authorization is required. 

Want uber-efficiency? Choose a solution like Myndshft—the only platform in the marketplace that handles both medical and pharma prior authorizations from one place. Talk about time-saving! 

Cost-Effectiveness

Managing two separate systems adds layers of complexity and cost. A unified prior auth software system reduces the overhead and simplifies administrative tasks. What’s more, the improved efficiency of a single platform for both types of prior authorizations leads to lower operational expenses. For example, automation reduces denials due to typos or missing information which eliminates 90% of rework associated with preventable denials. Plus, it accelerates the approval process, ensuring a smoother revenue cycle. 

Enhanced Patient Care

A simplified, quicker authorization process allows healthcare providers to focus on what matters most—patient care. Faster approvals lead to more timely treatments, elevating patient outcomes. (Bonus: Clinicians and staff enjoy better experiences too, leading to higher job satisfaction and reducing churn.) 

Future-Focused Adaptability

As regulations continue to evolve around interoperability, prior authorizations, and pharmacy benefit managers, having robust, integrated prior authorization software is no longer just an option—it’s a necessity. This future-focused technology helps you effortlessly keep pace with changes in the industry.

Revolutionize your prior authorization process with a robust solution

The intricacies between medical and pharma prior authorizations can have profound implications on healthcare delivery. Understanding these nuances is just the first step. Integrating  prior authorization software into your existing EHR or other system of record creates efficiencies that your staff, patients and bottom line will appreciate. 

Connect with Myndshft to get started.