Joseph Kim, MD, MPH, MBA:
Can you tell me about yourself, your practice, and the makeup of the team that works on the prior authorization paperwork and submits all that into the various portals?

Manish Shah, MD:
I am an internal medicine and pediatric physician. We have had this practice for approximately 19 years, and we see patients of all ages—from newborns to great grandparents. In addition, our practice has been using antiobesity agents before they were called “antiobesity agents” for certain classes. I help patients with their weight-loss journey through diet, exercise, counseling, and pharmacotherapy. Most recently, with the advent of some of the more powerful agents, my colleagues and I have been pleasantly surprised with patients’ results. So we are glad to be here to discuss our project and how we help patients.

Managing prior authorizations at my practice is a combined effort among medical assistants (MAs) and other treating healthcare professionals (HCPs). The MAs know that they must get certain codes into the patient’s chart for every visit, including a weight and calculating their BMI. Then the treating HCPs recognize the elevated BMI and notice that it is a problem that needs to be addressed.

On the back end of the prior authorization process, Martha is our MA and she catches feedback from the pharmacies as to what additional information needs to be provided. She also proactively gets that information into the patient’s chart or reminds treating HCPs to have certain details inputted into the chart themselves, so those details can all be consolidated and submitted to the applicable health insurance company.

Martha usually uses websites to determine patients’ coverage for their therapy, but some newer websites have come into play from different health insurance companies, which we then access and submit the information through there.

Joseph Kim, MD, MPH, MBA:
Let us talk more about the specifics. Can you describe how the process works when using websites that you just mentioned?

Martha Grugel, MA:
They basically follow the same concept. It is important that when you are submitting prior authorizations, regardless of which website you are using, you submit them with all the information required at that time. For example, we often attach patients’ chart notes with their BMI and any comorbidities that they may have because sometimes that plays into them getting coverage approved or not approved.

Manish Shah, MD:
The common comorbidities we see are heart disease, obstructive sleep apnea (OSA), and dyslipidemia. If patients have comorbidities, it can allow us to pass the bar for certain medications or health insurance companies. That becomes incredibly handy when we are trying to get these antiobesity agents covered.

Joseph Kim, MD, MPH, MBA:
You mentioned a number of the comorbidities that might affect coverage for these agents. Do you find that patients may not have been worked up for that potential diagnosis? If so, is that something that gets into the workflow of determining whether a patient might be eligible for treatment with an antiobesity agent?

Manish Shah, MD:
Absolutely. OSA has its own disease process, and unfortunately it has its own severe consequences, too. So knowing that a patient has OSA is always helpful. It is interesting that sometimes we must consider OSA as a comorbidity in patients who have not been diagnosed with it because typically my colleagues and myself would be looking at the same patient for the same reasons. Patients with overweight are candidates for having OSA. And we have to work that up to get these agents approved by insurance. However, to be fair, this workup is also helping patients. If they have undiagnosed OSA that is not treated, then we have helped them by saying, "Look, there is OSA here along with your other concerns, and we probably should address that because it comes with its own long-term consequences."

Joseph Kim, MD, MPH, MBA:
Can you tell me about the workflow process when you are considering treating a patient with an antiobesity agent?

Manish Shah, MD:
We have a patient with an increased BMI with comorbidities (ie, hypertension, heart disease, OSA, or dyslipidemia). We recognize that this patient probably would benefit from possibly a GLP-1 receptor agonist or dual GIP/GLP-1 receptor agonist. Those usually require prior authorization. But I also have seen prior authorization requirements with bupropion/naltrexone. And usually there is some pushback from the health insurance company about whether the agent’s coverage is going to be approved. That pushback has more to do with ensuring the patients’ details are correct and that the treatment is sensible for them.

On my end, when I see these comorbidities and the need, I approach patients and say, "Is it reasonable to discuss your weight?” if that is something that they have been concerned about. I would say that 9 of 10 patients are concerned about their weight when I address the issue or approach the topic. Then they will tell me, "Sure, I would be more than happy to try something new." In most cases, this it is not their first rodeo with weight management. Patients usually have tried other things in the past, such as diet, exercise, and other lifestyle modifications. Sometimes these behavioral changes will help them lose weight, but others are not as successful. And before prescribing antiobesity agents, patients usually present to us for a different reason. But when we bridge the topic of weight, they are more than happy to oblige and consider new treatment options.

In terms of prior authorizations, it is critical to document what they have tried to lose weight. Regarding lifestyle modifications, are they exercising? If so, how much exercise are they doing? What kind of diets they have tried in the past? I try to get a more complete picture of what patients have tried before, where they had some shortcomings in terms of success or failures, and then we try to move that needle along with medication.

Typically, I start with a GLP-1 or dual GIP/GLP-1 receptor agonist because they are pretty easy to use; a once-weekly injection vs a daily pill. Then the adverse event profile is management in terms of nausea, vomiting, diarrhea, and constipation. Patients tend to tolerate these agents better. In my experience, patients really tolerate these agents well when we slowly increase the dose.

I have found that to be a successful strategy. I also approach the topic and confirm that patients are willing to do an injection. If they are, I will provide a sample of the agent from the office. So the treating HCP or MA runs through how to give the injection and patients will physically administer their first one themselves in the office. I think that helps patients overcome concerns with using an injectable and the uncertainty of what to do with the medication when they get home. So patients have at least done their first injection and started their journey before they leave the office, which is very powerful for them.

The second part is picking the antiobesity agent that patients want and sending their prescription. Of course, if they have diabetes, the approach is different. But for patients without diabetes and as long as they have other risk factors, it is easier to get the agent’s use and coverage approved. Of note, some health insurers will pay for it just strictly for weight loss. Those are patients who have a BMI >30 or >40 without risk factors. These patients are typically approved to have their health insurance help cover the costs.

Now that the prescription has been sent, a prior authorization notification usually comes by email through the website. Martha receives those, so I will have her go through the steps from there.

Martha Grugel, MA:
When we submit the prior authorization, this is where all that documentation comes into play, as it is a big factor in the approval process. When submitting prior authorizations, I will check patients’ benefits, their primary diagnosis (which is always going to be the obesity), and any secondary diagnoses where you input their comorbidities if they have any. After completing these questions, I will attach their BMI and related office note. The office note should always have details on their diet and exercise (what they have done in the past) because many health insurance companies want to see that patients have tried lifestyle modifications within the last 3-6 months. Once I get all of that information inputted, I submit the prior authorization and wait to see if the agent’s coverage is approved.

Joseph Kim, MD, MPH, MBA:
Do you find that approval is instantaneous or do you have to wait a few days?

Martha Grugel, MA:
It depends on the health insurance company. If the agent is on their formulary, then some of the approvals are immediate. Others will take anywhere from 12-72 hours.

Joseph Kim, MD, MPH, MBA:
In terms of denials, appeals, and peer-to-peers, do those kinds of things happen within this class of medications? Does that change the results of one’s coverage determination?

Martha Grugel, MA:
It does happen. When these agents are denied, it is often because of a plan exclusion. And in that case there is not much that we can do. I recently have seen a denial that came with information on a website that the health insurance company wanted the patient to use to sign up for a wellness plan with them. Once the insurance saw the patient do that, after approximately 6 weeks, I was able to resubmit the prior authorization and got the coverage approval.

Then there are some coverage determinations that have been denied prior authorization, but I was able to appeal it. In most of those cases, the appeal is successful. But there are a few that have not been for certain reasons determined by the health insurance company. For example, one company may require a BMI of ≥37 before covering the cost. That is really the only time we have any trouble.

Joseph Kim, MD, MPH, MBA:
When it comes to explaining to patients that their treatment may or may not be covered, how do you have that discussion with them and set their expectations so that they are not surprised?

Manish Shah, MD:
I frequently tell patients that I am not sure if their health insurance will cover the agent. I look for a hint from our electronic health record via the formulary checker. If the formulary checker in our case has a green happy face, it is clear that there is coverage. Still I would not know if there is 100% coverage. Sometimes patients are able to just pick it up from the pharmacy right away or they will have to wait for a prior authorization.

I prepare them for that by sharing that unfortunately  these medications often require authorization by their health insurance. So patients understand that they may not be able to get their treatment right away, but that is also where the benefit and beauty of the sampling comes into play. In our practice, patients have already started their medication, so the journey has started before their prescription is filled.

It is obviously more frustrating for patients when they have had the medication for 4 weeks, love it, and then have to deal with the prior authorization process. This is especially true if there is a denial or noncoverage for obesity. However, I think it also helps them get past this issue now that manufacturers are providing their agents at a much lower cost than before; somewhere between $400 to $500 out of pocket. This is pretty steep, but at the same time some patients see the value in paying that cost after they have tried the agent. For the most part, patients know that there is going to be a process to get their coverage approved, and we try to approach that before the prescription is written. Of course, Martha is on the phone with patients after she has started the prior authorization.

In many ways, this is a team-based approach. Everybody who sees the patient is talking about the same thing: “Yes, there is going to be a delay, and it is normal. Do not be frustrated or dismayed by it. This is a standard process, and we know how to work it.”

Joseph Kim, MD, MPH, MBA:
You described the process of collecting progress notes and other pieces of information. Do you have any forms, templates, or shortcuts that you use to ensure that you have all the information you need prior to submission?

Martha Grugel, MA:
When we talk with patients about weight loss or their BMI, the treating HCP will usually use a template that lays out everything that they discuss, including the things patients have tried as far as diet, exercise, or other things in the past. That will all go into the progress note.

Joseph Kim, MD, MPH, MBA:
Are there any specific resources or tools that you have found that help streamline the process or guide you in the prior authorization submission?

Martha Grugel, MA:
I think it helps to stay up-to-date on new recommendations and indications for which these agents have been approved. For example, tirzepatide was recently approved for treating moderate to severe OSA in adults with obesity.¹ Semaglutide has since been approved for reducing the risk of major cardiovascular adverse events (ie, cardiovascular death, nonfatal myocardial infarction, or stroke) in adults with cardiovascular disease and overweight or obesity.² As long as you are up-to-date with that information, that really helps the process.

Manish Shah, MD:
It is always a changing landscape because as the indications come through, we get a little bit more to work with. Where the health insurance companies used to deny coverage, now there are additional indications for eligible patients.

I also will say that the health insurance companies have been fairly responsive to the new indications. When the OSA indication came out for tirzepatide, the health insurance companies were allowing coverage for the specific agent within a week or 2. And when the cardiovascular disease indication came out for semaglutide, that allowed for certain patients to get the specific agents a little bit quicker. I think that the health insurers—at least the ones that are covering these agents—are very responsive to additional indications being approved. The ones that are not, unfortunately are not. But there are also other ways to get the agents through the manufacturers themselves for patients who are denied coverage.

Joseph Kim, MD, MPH, MBA:
What are the biggest challenges you face with going through the prior authorization process?

Martha Grugel, MA:
I think the biggest hurdle is that it is time-consuming. Sometimes I have to get on the phone with the health insurance company. It is not all just an electronic process. So sometimes that takes a little bit longer than we would like it to be. Yet, as long as all the documentation is available, it is a fairly easy process.

Manish Shah, MD:
For HCPs, I think about unreimbursed time. We have seen the patients, taken care of them, and written their prescription. And I will think that I have dotted all the I’s and crossed all the T’s. Then to be asked to provide proof of all that is frustrating to say the least. And on top of that, it takes up staff time.

You may finish the prior authorization and the next hurdle appears. There is a little bit of a cat and mouse game that I feel we are involved in. And that is a little bit unfair because it is time that is not reimbursable.

Obviously, we are doing it all for patients; we would not be doing it otherwise. However, this is one thing that likely will need to be addressed in the near future: the weight that prior authorizations carry. And this is not just an issue with antiobesity agents. A whole bunch of other medications have the same issue where HCPs must prove to the health insurer that the patient needs it. Hopefully, no HCP is prescribing an agent to a patient who does not need it.

Joseph Kim, MD, MPH, MBA:
Can you think of an example of a particularly difficult prior authorization case and how you handled it?

Martha Grugel, MA:
We had a recent prior authorization for a patient with obesity and comorbidities. Her health insurance wanted us to prove that the patient had coronary artery disease in order to provide coverage. We did the testing that they wanted to prove the diagnosis. After submitting that additional testing, they then wanted us to prove that the patient had peripheral arterial disease (PAD). We did an ankle-brachial index that resulted in borderline abnormal, so we had to send her for additional testing.

This is an example of where health insurance initially wanted one thing and once we proved it, the company wanted something else and then something else.

Manish Shah, MD:
The frustrating thing is for the patients who need the treatment. In this patient’s case it was a positive calcium score, an indeterminate PAD screen, and finally an arterial ultrasound to prove the presence or absence of PAD.

In the end, the patient was on the sideline saying, "What else at this point?" The problem in this particular patient case was that the agent was previously covered by her health insurance. The health insurance, because of a plan year change, decided that it was no longer going to cover the agent or there were new stipulations for how it would be covered the following year. It was messy for the patient because she had been taking it previously and now had to go off the medication because of a denial.

Then initially we had issues where people who rightly should be on an antiobesity agent were being denied without specific reasons. We would call the health insurance companies and they told us that they would cover it if patients have type 2 diabetes (T2D). We would have to tell them that these patients did not have T2D, which is why they were receiving the obesity version of this medication. Then companies would agree that the patients should not say that they have T2D when they do not and then tell us that they would not cover the agent at all. It was a cat and mouse game. We had to go through this maze to then be told that they would deny coverage. It was not the fact that they were denying coverage; rather, it was that they could have easily declared that there would be no coverage from the beginning. If the issue is that coverage is not available, why make us go through the prior authorization process to begin with?

I understand that health insurance companies were trying to figure out their own landscape with regards to getting the right funds for these agents. But on the flip side, it felt unfair and frustrating for us.

Joseph Kim, MD, MPH, MBA:
In considering hiring new staff members, training them, and teaching them about what is required to complete a prior authorization, what are the tips or strategies that you would use to ensure that they are being efficient?

Martha Grugel, MA:
The most important thing is just remembering to attach all the necessary documentation. You just need 1 office visit note; really just ensuring that new staff members receive training for these agents and how they can be used. Everything else just falls into place because these websites are very self-explanatory. They ask specific questions that you can find in the patient’s chart and remind you to upload the supporting documentation.

Joseph Kim, MD, MPH, MBA:
Dr Shah, any tips for other HCPs out there who perhaps are not documenting as thoroughly or might be missing critical components of documentation?

Manish Shah, MD:
There are 2 parts to that question. One is that sometimes we may bring up antiobesity agents a little too early in the conversation. I think that some may want to slow that down a bit. This is where a template can help. Once patients decide to start talking about weight management, you pull out your obesity template and run through your questions. Are you concerned about your weight? Is it something that we are okay to discuss? What have you done to lose weight in the past? How much exercise do you get? What things do you think are wrong with your diet currently? Where do you think that you are not successful?

If you have these questions preloaded, you can approach the subject a little bit easier. Furthermore, you have a templated form to hit your highlights.

Then you can add in questions regarding comorbidities. Is there a history of OSA? Have you had heart disease that you may not have discussed previously? That way these points are all in 1 place and when you go to search them, you can find them easily for your prior authorization.

I also tell Martha that we can always add an addendum to the progress note later. You are not making it up if you call patients back and ask about their medical history. You can ask those questions afterwards if you did not get them answered during the visit. That is okay to do. We can add an addendum to that visit, have the MA run through a few questions, and submit that as part of the progress note.

Joseph Kim, MD, MPH, MBA:
Is there anything else regarding prior authorizations that is important to cover?

Manish Shah, MD:
I think that we touched base on a little bit of everything. Part of it starts in the exam room with getting a reasonable history for weight loss in general. That will help you determine which antiobesity agent is best and help you identify where the patient is having the most challenges; all of which may guide the treatment plan.

I think that historical piece really does help you get a better idea of where patients are coming from and meeting them where they are at. It is also the easiest way to get them to start their weight-loss journey. Then it helps with completing prior authorizations on the backend. If there is anything that I would do a little bit more, it would be to catch that history early because that sets the foundation. Then you can start anything that you need to do from there. It supports your documentation requirements for prescribing antiobesity agents down the road, too.

Martha Grugel, MA:
The biggest thing is having that documentation completed and ready. Of course, considering other things that may relate and help patients get their treatment covered, there is always the option for additional diagnosis codes past the obesity code. I think that including all of that history is the biggest help.