Aug 19, 2024
Apr 3, 2025
Written By Elizabeth Cifers
Last month, we discussed what information should be included in the documentation for a prior authorization for a retina drug. We touched briefly on the specific requirements for changing drugs. Still, this topic deserves a short article due to the reimbursement risk created by the additional documentation demands, and it isn’t uncommon for documentation to fall short when changing drugs.
In addition to standard chart notes (see last month’s article for reference), documentation for prior authorization for switching a retina drug should include the medical reason for doing so.
The physician should clearly explain how the current drug fails to achieve the desired medical outcome, what the physician wants to see, and why the physician expects the new drug to succeed in meeting the outcome. This explanation need not be lengthy but should effectively communicate the rationale for switching drugs using plain language and logic.
It’s important to note that the reason for changing drugs must be medical—it can’t be for convenience. The medical justification could be to achieve a more significant reduction in edema, better visual acuity, or more stability in the patient's disease process. While it may be an additional advantage if the new drug allows more time between injections, the longer time between injections isn’t the primary reason for wishing to change drugs.
When payers encounter a prior authorization request for a new drug for an established patient, many require chart notes before providing a pre-authorization or after the fact once the drug has been injected. The payer will review documentation for medical justification. Proper chart notes and valid medical reasoning should support the drug change. Retina specialists can reduce reimbursement risk by exercising prudence when changing drugs and documenting appropriately.
Maximizing reimbursement is crucial to maintaining a successful retina practice. Get ahead of the game with the help of documentation, coding, and billing consultant Elizabeth Cifers. Elizabeth has decades of industry expertise and the range of skills necessary to solve isolated challenges or optimize your entire revenue cycle if desired. Schedule a free initial consultation to discuss your practice’s needs and potential solutions here.
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