How Prior Authorizations Impact Biologic Therapy and Strategies for Success
Feb 17, 2025
Overcoming Barriers: How Prior Authorizations Impact Biologic Therapy and Strategies for Success
If you've ever dealt with prior authorizations, you know the struggle is real. The paperwork, the delays, the endless back-and-forth with insurance companies—it can feel like an uphill battle that never ends. And for patients who need biologic therapy, these hurdles can mean weeks or even months of waiting for treatment that could drastically improve their quality of life.
As healthcare professionals—whether you're a biologic coordinator, prior authorization specialist, or provider—your role in this process is critical. You’re the one making sure patients get access to the medications they need. But how do we make this process easier, faster, and less frustrating?
The good news? You’re not alone.
The even better news? There are strategies that actually work.
Let’s dive into the roadblocks that make prior authorizations so challenging—and how you can overcome them.
Why Are Prior Authorizations Such a Headache?
Let’s break down why this process is so frustrating:
✅ Insurance Companies Want to Control Costs
Biologic therapies are expensive—often costing thousands of dollars per month. Because of this, insurance companies put prior authorization (PA) requirements in place to ensure that these medications are used appropriately and cost-effectively.
✅ The Process is Time-Consuming
Most PAs involve multiple steps:
1️⃣ Prescription is written → The provider prescribes a biologic that requires PA.
2️⃣ Office submits the request → This includes diagnosis codes, treatment history, and clinical justification.
3️⃣ Insurance company reviews the case → They compare it against their coverage criteria (which varies from payer to payer).
4️⃣ Denials & Appeals → Even when patients meet criteria, denials happen. That means more paperwork, more calls, and more delays.
✅ Approval Timelines Are Inconsistent
Some requests take a few days, others weeks or months.
If additional documentation is needed, it starts the clock all over again.
If denied, appeals can take even longer.
✅ Patients Get Stuck in the Waiting Game
They don’t understand the process and often feel left in the dark.
They can’t start treatment until approvals come through.
If denied, they may have to explore other (less effective) options.
And then there’s the burden on your office—your team is spending hours tracking down insurance reps, re-submitting requests, and managing appeals. It’s exhausting.
Winning Strategies for Prior Authorizations
Now that we know the challenges, let’s talk about how to win at this game.
✅ 1. Master the Art of Documentation
Documentation can make or break a prior authorization request. If you’re missing even one piece of information, you risk a denial.
✔ Include all necessary details upfront:
Accurate diagnosis codes
Past treatment history (what was tried, why it didn’t work)
Clinical justification that aligns with payer requirements
✔ Use Templates & Checklists:
Standardized templates save time and frustration.
A simple checklist ensures nothing is forgotten before submission.
💡 Pro Tip: Keep an up-to-date database of insurance requirements for different biologics. This way, your team isn’t starting from scratch with every new request.
📑 2. Standardize Your PA Process & Stay Organized
If your office isn’t tracking PAs effectively, it’s easy to lose requests in the shuffle.
✔ Assign a Dedicated Team Member
Whether it’s a biologic coordinator or an access team specialist, having a go-to person makes a huge difference.
✔ Create a PA Workflow
Who is responsible for submitting the PA?
How will denials be handled?
How will patients be updated?
✔ Use Tracking Tools
Spreadsheets, EMR dashboards, or dedicated PA software can keep everything in one place.
📞 3. Build Strong Relationships with Insurance Reps
Yes, we know. Talking to insurance companies is the worst. But having a direct contact with major payers can make approvals faster.
✔ Find out who your payer reps are—get their emails, their direct phone numbers.
✔ Stay updated on policy changes—insurance criteria shift all the time.
✔ If a request gets denied, call instead of just re-submitting—sometimes a quick conversation can save you days of waiting.
💡 Pro Tip: If an insurance rep gives you conflicting information, document it. That way, you have proof if you need to appeal later.
🖥️ 4. Use Technology to Your Advantage
If you’re still faxing prior authorization requests (cringe), it’s time for an upgrade.
✔ Switch to Electronic Prior Authorization (ePA) Systems
Automates the process
Cuts down on back-and-forth paperwork
Reduces errors & speeds up approvals
✔ Use Patient Portals for Communication
Patients can check the status of their PA request without calling the office.
✔ Leverage AI & Analytics
Track approval times, denial trends, and payer patterns to improve your process.
Making Medication Access Easier for Patients
Prior authorizations are only part of the challenge—ensuring patients can actually afford and receive their medications is another hurdle.
🏥 Educate Patients on the Process
Most patients don’t understand what goes into getting their biologic approved. Help them by:
Setting realistic expectations (this may take time, but we’re on it!)
Explaining what they can do (calling their insurance, submitting additional paperwork)
Keeping them updated so they’re not left wondering
💊 Explore Patient Assistance & Alternative Options
If insurance denies coverage or the cost is too high:
✔ Check Manufacturer Assistance Programs (many offer free or reduced-cost bridge programs).
✔ Appeal Denials with Peer-to-Peer Reviews (sometimes, one conversation with a medical director can turn things around).
Empowering Your Access Teams
Biologic access teams are the backbone of this process. If you’re in this role—you are a game-changer. Here’s how to make sure your team is set up for success:
✔ Provide ongoing education & training—insurance policies change constantly.
✔ Give them the tools they need—robust data management systems, ePA tools, and adequate staffing.
✔ Encourage open communication—regular check-ins with providers & office staff keep things moving.
✔ Recognize their work—this process is hard, and access teams deserve appreciation for what they do!
Final Thoughts: Keep Fighting the Good Fight
Prior authorizations may feel like a never-ending battle, but with the right strategies, technology, and teamwork, you can cut through the red tape and get your patients the treatments they need.
💪 Your work MATTERS. Keep pushing, keep advocating, and keep fighting for your patients.
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At BC Educators, we are dedicated to empowering biologic coordinators, healthcare professionals, and patient advocates with the education, tools, and resources needed to optimize patient care. From expert-led webinars to hands-on training, we provide comprehensive support to help you navigate the ever-evolving landscape of specialty medications and prior authorizations.