Implementing a letter template to expedite specialty medication appeal letter submission

Background

Prior authorizations (PAs) for biologic medications, used to treat inflammatory bowel disease (IBD), are often denied by pharmacy benefits managers and can require a complex appeal process for patients to gain access to medication.

Objective

This quality improvement project evaluated the impact of implementing a standardized appeal letter template and customizable clinical rationale letter content on specialty pharmacist workflow and workload in an integrated hospital health system specialty pharmacy (HSSP) IBD clinic.

Practice description

This initiative was conducted in an IBD outpatient clinic at a tertiary academic medical center with an integrated HSSP whose specialty pharmacists work collaboratively with providers to manage specialty medications.

Practice innovation

A letter template was created in the electronic health record (EHR) for pharmacists to use when submitting appeal letters. The template automatically populates patient results from recent labs, imaging, and clinic visit notes as part of the appeal documentation. Clinical rationale letter content was developed for the most common appeal reasons using EHR functionality that allows the creation of standardized notes that can be shared among team members and customized at time of use.

Evaluation method

An analysis of 2 months of data preimplementation/postimplementation was conducted using descriptive statistics to report the number of appeals submitted, time from PA denial to appeal submission, and appeal approval rate. A pharmacist postimplementation satisfaction score was also collected.

Results

The number of appeals submitted preimplementation (n = 73) and postimplementation (n = 73) was the same. Postimplementation, 89% of appeals were submitted within 3 days of PA denial compared to 29% preimplementation. PA approval rate was high (93%) preimplementation and postimplementation. Overall pharmacist satisfaction was 9.7 out of 10.

Conclusion

Implementation of an appeal letter template and standardized clinical rationale letter content in the EHR led to decreased time to appeal submission and high specialty pharmacist satisfaction.