CPAP Module 14, Section 3: Identifying Systemic vs. Case-Specific Issues
MODULE 14: DENIALS: ROOT CAUSE ANALYSIS

Section 3: Identifying Systemic vs. Case-Specific Issues

Moving from Case Repair to Workflow Re-engineering.

SECTION 14.3

Identifying Systemic vs. Case-Specific Issues

The Key to Developing Scalable, High-Impact Solutions.

14.3.1 The “Why”: The Multiplier Effect of Fixing the System

Thus far in your career, your success has been measured one patient at a time. Resolving a complex PA for a single patient is a significant victory. It delivers a tangible, immediate benefit and represents the core of patient advocacy. This is the essential, foundational work of a PA specialist. However, to ascend to the level of a true expert—a leader in the field—you must learn to elevate your perspective from the individual case to the underlying system. This section is dedicated to teaching you that crucial leap: the ability to distinguish between a one-time, isolated error (a case-specific issue) and a recurring, predictable flaw in a process (a systemic issue).

Why is this distinction so critical? Because it determines the scale of your impact. Fixing a case-specific issue helps one patient, one time. It’s a necessary act of repair. But identifying and fixing a systemic issue can prevent dozens, or even hundreds, of future denials. It is not an act of repair; it is an act of re-engineering. It creates a multiplier effect that scales your expertise far beyond the number of hours you have in a day. When you solve a systemic problem, you are creating a permanent improvement in the workflow that benefits every future patient and every staff member who interacts with that process.

This is the transition from being a pharmacist who is good at PAs to being a pharmacist who makes an entire clinic or health system better at PAs. It requires a shift in mindset from a reactive problem-solver to a proactive process improvement analyst. You will learn to use denial data not just to win appeals, but to diagnose the health of a clinical workflow. Is a particular clinic consistently failing to provide necessary chart notes for a specific drug? That’s not ten individual problems; that’s one systemic problem with a single, scalable solution. By learning to see these patterns, you position yourself as a strategic partner to the clinics you support. You move beyond fixing their problems to providing them with the tools and knowledge to prevent those problems from ever occurring. This is the pinnacle of the CPAP role: creating systems that make the right thing to do the easy thing to do, ensuring more first-pass approvals and reducing the need for reactive interventions altogether.

Retail Pharmacist Analogy: The Recurring “Missing SIG” Problem

Imagine it’s a busy Monday. You receive an e-prescription from a local urgent care for amoxicillin suspension for a child. The prescription simply says “Amoxicillin 250mg/5mL,” with no dose, frequency, or duration. This is a case-specific issue. It’s an error, but it’s an isolated one. Your solution is simple and direct: you call the urgent care, get the clarification (“Give 5mL twice daily for 10 days”), document it, and fill the prescription. You have fixed the problem for this one patient.

Now, imagine that over the next two weeks, you receive fifteen more e-prescriptions for pediatric antibiotics from that same urgent care, and every single one is missing the full directions. You now have a systemic issue. The root cause is not a single typo; it’s a flaw in their workflow. Calling the on-duty doctor fifteen separate times is inefficient and treats the symptom, not the disease. Your strategy must evolve.

The systemic solution is to stop fixing the individual prescriptions and start fixing the prescribing process. You don’t just call for a clarification; you call to speak with the clinic manager or lead nurse. Your script changes: “Hi, this is the pharmacist from ABC Pharmacy. I’m calling because we’ve noticed a pattern. It seems like many of your pediatric antibiotic e-prescriptions are transmitting without the directions. I suspect there might be an issue with how the SIG is being entered into your EMR’s free-text field. Could we perhaps look into this? Maybe we can build a dropdown template for the most common antibiotics to prevent this from happening?”

By making that one strategic call, you are no longer just a pharmacist fixing a single error. You are a process improvement consultant. If the clinic implements your suggestion, you will have prevented hundreds of future callbacks, saved hours of work for both your staff and theirs, and ensured that every future pediatric patient gets their medication faster. That is the power of identifying and addressing a systemic issue.

14.3.2 Differentiating the Signal from the Noise: Characteristics of Systemic vs. Case-Specific Denials

The first step in diagnosing a problem is recognizing its symptoms. Systemic and case-specific issues present with different characteristics. Learning to spot these differences is how you begin to see the patterns in denial data.

Characteristic Case-Specific Issue (The “One-Off”) Systemic Issue (The “Pattern”)
Frequency & Scope Isolated Incident: Happens once or very rarely. Affects a single patient or request.

Example: A medical assistant accidentally faxes the PA request for Patient A to the wrong insurance company. This is a simple human error that is unlikely to be immediately repeated.

 Recurring Pattern: The same denial reason appears repeatedly over time. Affects multiple patients, often from the same clinic or for the same drug.

Example: You notice that 5 out of the last 10 requests for a specific infused drug from the oncology clinic have been denied for “missing J-code.”
Root Cause Unique Circumstance or Simple Error: Often caused by a momentary lapse, a typo, a patient’s unusually complex history, or a one-time misunderstanding.

Example: A denial for “insufficient information” happens because the patient’s specialist appointment, containing the key clinical note, was only yesterday and hasn’t been transcribed into the EHR yet.

 Flawed Process, Knowledge Gap, or Technology Failure: The problem is baked into the standard workflow, a lack of training, or a poorly configured EMR.

Example: The clinic’s standard PA intake form does not have a dedicated field for “prior therapies,” so the staff consistently forgets to include this information, leading to repeated step therapy denials.
Required Solution Direct Intervention & Correction: A one-time fix for that specific case.

Example: You call the clinic, get the missing lab value for the patient, and submit a corrected request or appeal. The problem is solved for that patient.

 Process Re-design, Education, or Tool Creation: Requires a higher-level solution that changes the workflow for everyone.

Example: You work with the clinic to create a one-page “PA Submission Checklist” for that specific drug, ensuring the staff gathers all required elements upfront for every future patient.
Your Diagnostic Clue Surprise or Uniqueness: Your reaction is, “That’s odd, I haven’t seen that before.” or “This patient’s situation is really unusual.”

Example: A denial because the patient’s rare genetic marker, required by policy, was documented in an obscure, non-standard lab report that was difficult to find.

 Déjà vu or Predictability: Your reaction is, “Oh, it’s the denial from the GI clinic for Drug X again. I bet I know why.”

Example: You receive a denial for a Crohn’s disease biologic from the GI clinic and correctly predict, before even reading the details, that it was denied for a missing fecal calprotectin level, because that’s the reason for the last five denials.

14.3.3 The CPAP’s Root Cause Analysis (RCA) Playbook

Once you suspect a systemic issue, you need a structured method to diagnose its origin and develop an effective solution. Root Cause Analysis (RCA) is a formal problem-solving methodology used in high-reliability fields like aviation and healthcare. We will adapt it into a practical playbook for the PA specialist.

A 5-Step Playbook for Systemic Problem Solving
  1. Step 1: Detect and Quantify the Pattern

    You can’t fix what you don’t measure. The first step is to move from a “gut feeling” to hard data. Start a simple denial tracking log (an Excel sheet is perfect for this). Your log should include: Date, Patient, Drug, Payer, Clinic/Provider, Denial Reason (Categorized), and Outcome. When you suspect a pattern, filter your log. For example, “Show me all denials from the Cardiology clinic for Entresto in the last 90 days.” The data will confirm your suspicion. Goal: To be able to state the problem with data: “The Cardiology clinic has an 80% initial denial rate for Entresto, with 90% of those denials due to ‘missing documentation of ACE/ARB failure’.”

  2. Step 2: Map the Current State Workflow

    You must understand the process before you can fix it. Talk to the staff at the clinic (MAs, nurses). Your goal is to create a simple flowchart of how a PA request is currently handled. It might look like this: 1. Provider prescribes Entresto in EHR -> 2. A task fires to the MA’s inbox -> 3. MA opens the PA request in the portal -> 4. MA attaches the last office visit note -> 5. MA submits the request. This visual map often immediately reveals the weak point in the chain.

  3. Step 3: Perform a “5 Whys” Analysis to Find the Root Cause

    This is the core diagnostic technique. Starting with the problem, you ask “Why?” repeatedly until you move past the surface-level symptoms to the foundational cause.

    Problem: Entresto requests are being denied for missing ACE/ARB failure documentation.

    1. Why? Because the required chart notes showing the ACE/ARB trial were not attached.

    2. Why? Because the MAs are only attaching the most recent office visit note.

    3. Why? Because their standard workflow for all PAs is to attach only the most recent note, and they don’t know this specific drug has a different requirement.

    4. Why? Because there is no specific training or job aid for drug-specific PA requirements.

    5. Why? Because the system relies entirely on individual staff memory, which is unreliable for complex, ever-changing payer rules. (This is the root cause).

  4. Step 4: Develop a Targeted Solution (The “Countermeasure”)

    Your solution must directly address the root cause identified in Step 3. Since the root cause is a lack of a reliable system for remembering drug-specific requirements, the solution must be to create one. Brainstorm potential countermeasures:

    • Good Solution: An educational in-service to train the MAs on Entresto requirements.
    • Better Solution: A durable, laminated “Entresto PA Checklist” taped to the computer monitors in the MA pod.
    • Best Solution: Working with the clinic and IT to build the checklist directly into the EHR as a required step or smart-phrase template that fires when Entresto is prescribed.

  5. Step 5: Implement, Monitor, and Validate

    Implement the chosen solution collaboratively with the clinic. Then, continue tracking the data. Set a reminder to check your denial log in 30 and 90 days. Goal: To validate that the solution worked. “After implementing the Entresto checklist on Nov 1st, the initial denial rate for the Cardiology clinic dropped from 80% to 15%.” This closes the loop and demonstrates your value.

14.3.4 Case Study: From Repetitive Appeals to a Systemic Fix

Let’s walk through a complete, real-world scenario to see how a CPAP specialist transitions from case manager to process improvement leader.

The Scenario: The Rheumatology Clinic’s Xeljanz Problem

A CPAP specialist embedded in a health system notes a high volume of time-consuming, peer-to-peer appeals for the drug Xeljanz (tofacitinib) coming from the Rheumatology department for patients with rheumatoid arthritis (RA).

  • 1
    Detection and Quantification

    The specialist filters her denial tracking log for “Xeljanz,” “Rheumatology,” and “denial reason” over the past quarter. The data is stark: 25 initial requests, 20 of which were denied (80% denial rate). The denial reason for 18 of the 20 denials (90%) is identical: “Failure to meet medical necessity criteria; no documented trial and failure of a biologic DMARD.” She has quantified the systemic problem.

  • 2
    Workflow Mapping

    She meets with the clinic’s lead MA and maps the process. The clinic uses a general “Biologic PA Form” for all of their drugs. The form has a field for “Prior Therapies,” but the MAs typically only list the conventional DMARDs (like methotrexate) because Xeljanz is an oral drug, and they associate “biologics” with injectables. They don’t realize that for payers, Xeljanz (a JAK inhibitor) is positioned *after* a trial of an injectable biologic (like Humira or Enbrel).

  • 3
    The “5 Whys” Analysis

    Problem: Xeljanz denied for no trial of a biologic DMARD.

    1. Why? Because the prior trial of Humira wasn’t documented on the PA form.

    2. Why? Because the MA didn’t think to include it.

    3. Why? Because they consider Xeljanz an “oral” drug and the form asks about “biologics,” which they interpret as injectables.

    4. Why? Because their internal form and workflow create a false mental categorization that doesn’t match the payer’s clinical policy.

    5. Why? Because the clinic’s tools have not been updated to reflect the specific, nuanced place in therapy for JAK inhibitors. (Root Cause)

  • 4
    Developing the Countermeasure

    The specialist realizes that retraining alone won’t work because the confusing form will still exist. She proposes a systemic solution: Modifying the “Biologic PA Form.” She works with the clinic manager to add a specific, hard-to-miss section:
    “— For JAK Inhibitors (Xeljanz, Rinvoq, Olumiant) ONLY —“
    This section includes a mandatory checkbox and field: “[ ] Documented trial of biologic DMARD (e.g., Humira, Enbrel). Please specify drug and failure reason: ______________”

  • 5
    Implementation and Validation (The Result)

    The new form is implemented. The CPAP specialist continues to track the data. In the next quarter, the Rheumatology clinic submits 30 requests for Xeljanz. The initial denial rate drops from 80% to 10%. The two denials that occur are for unique, case-specific reasons, not the previous systemic failure. The specialist has saved the clinic, the payer, and her own department countless hours of rework and has significantly accelerated patient access to therapy.

14.3.5 Critical Pitfalls in Systemic Improvement

While the impact of fixing systemic issues is enormous, the process is fraught with interpersonal and logistical challenges. Awareness of these traps is essential for success.

Human Factors: The Hardest Part of Process Improvement
  • The Blame Game vs. Process Focus: It is absolutely critical that your analysis focuses on the process, not the people. The goal is not to find out “who is messing up,” but “where is the process letting our staff down?” Trap: Approaching a clinic with an accusatory tone (“Your MAs keep forgetting to…”). This creates defensiveness and shuts down collaboration. Solution: Frame the issue collaboratively and system-focused. “I’ve noticed the payers have a tricky requirement for this drug, and our current workflow doesn’t make it easy to remember. How can we build a better process together?”
  • Trying to Boil the Ocean: When you first start looking for systemic issues, you will see them everywhere. The temptation is to try and fix everything at once, overwhelming yourself and the clinics you support. Trap: Creating a massive, 10-point plan to overhaul the entire PA process for a clinic. This is destined for failure. Solution: Use your data to prioritize. Start with the single most frequent and time-consuming denial. Get a small, measurable win. Success breeds trust and makes it easier to tackle the next problem.
  • Imposing Solutions vs. Co-designing Them: As the PA expert, you may see the “perfect” solution immediately. However, a solution that is not embraced by the frontline staff who have to use it is a worthless solution. Trap: Designing a beautiful, complex new form or checklist in a vacuum and then “giving” it to the clinic staff. They will likely ignore it and revert to their old habits. Solution: Practice collaborative design. Bring your analysis to the clinic staff and ask them, “Here is the problem. What ideas do you have for a tool that would make this easier for you in your daily workflow?” A simple solution they help create is infinitely more effective than a perfect solution they resent.