Answer Prior Authorization Operations Case more questions on document For this project, please spend 1-2 hours creating a Google doc that outlines your answers to the questions below. If you have an

Prior Authorization Operations Case
For this project, please spend 1-2 hours creating a Google doc that outlines your answers to the questions below. If you have any questions, please reach out to us via email.
Background on Prior Authorization

Prior authorization is a procedure used by health insurance companies to determine if they will cover a prescribed medication. This process is aimed at ensuring the treatment is medically necessary and aligns with the insurer's coverage policies. Unfortunately, this process can be time consuming and confusing to navigate for both patients and their providers.
The general process is as follows:
1. A healthcare provider prescribes medication for a patient.
2. If the medication is not automatically covered under the patient's insurance plan, a prior authorization request form must be submitted to the insurance company. The form requires detailed information about the patient's medical condition and why this specific medication is necessary.

3. The insurance company reviews the request to assess the medical necessity of the medication and whether or not it should be covered under the patient's specific policy. This process typically takes a few days, though some reviews are automated and are completed instantly.
4. The insurance company either approves or denies the prior authorization request and responds via fax.
a. If approved, the patient’s medication will be covered by their insurance at the pharmacy.
b. If denied, the provider must decide if a change in medication is required or if they should “appeal” the insurance company’s decision by writing a letter about the need for coverage.
Questions

1. PA example scenario: Assume you are completing a PA for a chronic migraine patient who has been prescribed Emgality for the first time. The patient’s health insurance is United Healthcare.
a. Emgality typically requires that patients complete step therapy requirements. Research and list out the step therapy requirements for this medication for the patient’s insurance.
Include links to any references you used.
b. In filling out the PA, you realize the documentation does not show that the patient has
completed all step therapy requirements from the plan. Draft an email to the provider
requesting any additional information you think you need to complete a PA for Emgality.
c. The patient has never had to go through a PA process before, so they don’t understand
why their prescription is not ready yet or what current status is. Draft a text message explaining the situation of their Emgality prescription to the patient. Remember that
texts should be succinct while conveying the most important information
2. Analyzing our PA operations: the chart below shows the average minutes spent by an operations associate on completing and submitting a prior authorization form (note data is
illustrative). Clearly state any assumptions you are making.
a. How many hours did it take to complete 100 PAs per day in January 2024 vs. April
2024?
b. How many Operations associates were required to handle these 100 PAs per day in January 2024 vs. April 2024? (assuming these operations associates were only working
on PAs) :

c. What do you think has driven the decrease in time per PA?
d. What do you think time per PA will be in May 2024 and June 2024? Why?

3. PA process execution
a. You have 50 prior authorizations to process today. How would you prioritize them?
Please explain your thought process and approach.
b. If you discover that you mistakenly sent a prior authorization without all required
documentation, what steps would you take to resolve the issue and prevent future
mistakes?