CPAP Module 7, Section 3: Coordination with Stakeholders
MODULE 7: THE PHARMACIST’S INVESTIGATIVE TOOLKIT

Section 3: Coordination with Patient, Prescriber, and Billing Staff

The Art of Triage, Communication, and Stakeholder Alignment.

SECTION 7.3

Coordination with Patient, Prescriber, and Billing Staff

A masterclass in communication, providing scripts and workflows for efficiently gathering missing information, clarifying discrepancies, and ensuring all stakeholders are aligned.

7.3.1 The “Why”: From Analyst to Air Traffic Controller

In the preceding sections, you have cultivated the skills of a detective and a forensic analyst. You have learned to wield digital tools to extract raw data and the interpretive skills to synthesize that data into actionable intelligence. You can now build a complete, accurate profile of a patient’s benefits and identify every potential barrier to access. However, this intelligence is worthless if it remains confined to your computer screen. The final, and arguably most challenging, transformation in your role is from a solitary analyst to a central communications hub—an air traffic controller for critical information.

The prior authorization process does not exist in a vacuum. It is a complex ballet involving at least three distinct groups of stakeholders, each with their own priorities, communication styles, and specialized languages:

  • The Prescriber’s Office: Overwhelmed with clinical duties, they value brevity, clarity, and actionable recommendations. They speak the language of diagnoses, clinical evidence, and outcomes.
  • The Patient: Often anxious, confused by insurance jargon, and primarily concerned with two things: “When can I get my medicine?” and “How much will it cost?” They speak the language of fear, hope, and finance.
  • The Billing Staff / Financial Navigators: Experts in a world of codes (ICD-10, CPT, J-codes), they are focused on reimbursement, claim submission, and revenue cycles. They speak the language of procedure codes and financial clearance.

A prior authorization fails not just because of incorrect clinical data, but because of a breakdown in communication between these three groups. The prescriber doesn’t understand the patient’s cost-share, the patient doesn’t understand the clinical reason for the delay, and the billing office doesn’t have the correct authorization on file to submit a clean claim. Your role as the PA pharmacist is to stand at the center of this triangle, acting as the universal translator and process coordinator. You must ensure the right information gets to the right person, in the right format, at the right time. This section is a deep dive into the “soft skills” that produce hard results. Mastering these communication strategies is what elevates you from a technician who processes tasks to a specialist who manages cases and influences outcomes.

Pharmacist Analogy: The Compounding Pharmacist as Project Manager

Think about the last time you prepared a complex, multi-ingredient compound, like a “magic mouthwash” or a specialized hormone cream. You weren’t just a chemist mixing substances; you were a project manager coordinating a multi-step process.

Your first step was to analyze the prescription (the PA request). You might see an ambiguous ingredient or a non-standard concentration. What did you do? You initiated a coordination call with the prescriber to clarify. “Dr. Smith, for the magic mouthwash, did you want the 2% viscous lidocaine or the standard aqueous solution? The viscous solution will be thicker but may not be covered.” You present a clear question with clinical and financial context.

Next, you considered the final product. You knew it would not be ready for 15 minutes and that it would have a higher-than-usual cost. You initiated a coordination conversation with the patient. “Mr. Jones, this is a special compound we have to make for you. It will be ready in about one hour, and the cost will be $65 as it’s not covered by your standard copay. Is that okay?” You manage expectations on timing and cost.

Finally, you looked at your inventory and realized you were out of a key ingredient, nystatin powder. You initiated a coordination task with your technician or inventory system (your “billing staff”). You confirmed the correct NDC, ordered it from the wholesaler for next-day delivery, and ensured the cost was properly accounted for.

The successful completion of that compound depended entirely on your ability to proactively communicate and coordinate with three different stakeholders. A prior authorization is the ultimate compounding project. It requires you to gather clinical clarifications, manage patient expectations, and ensure financial clearance, all through precise, expert communication.

7.3.2 The Triage Mindset: Prioritizing Your Communication Queue

Before a single phone call is made or a message is sent, the expert PA pharmacist must first bring order to their workload. On any given day, your queue may contain dozens of cases, each with its own unique set of needs. Treating every case as equally important is a recipe for inefficiency and can lead to dangerous delays for the most critical patients. You must adopt the mindset of an emergency room physician, constantly triaging your queue to ensure the most vital communications are prioritized. The most effective method for this is the Urgency/Complexity Matrix.

This matrix is a mental model that allows you to categorize every case based on two simple axes: its clinical urgency to the patient and its administrative complexity. By plotting each case on this grid, you can instantly determine the priority and the appropriate communication strategy.

The Urgency/Complexity Triage Matrix
CLINICAL URGENCY

Quadrant 1: All Hands on Deck

Cases: New oncology diagnosis needing immediate chemotherapy; post-transplant patient needing immunosuppressants; non-formulary exception for a life-sustaining drug.

Strategy: Highest Priority. Requires immediate, synchronous communication (phone calls). Must be worked continuously until resolved.

Quadrant 2: Fast Lane

Cases: Urgent antibiotic for a resistant infection; anti-epileptic for a patient with breakthrough seizures; standard PA for a formulary specialty drug with a clear policy.

Strategy: High Priority. Often manageable with efficient, templated electronic communication (EHR message, fax) that provides all necessary info for a quick turnaround.

Quadrant 3: The Long Game

Cases: A second-level appeal for a complex case; gathering documentation for a new-to-market drug with no established policy; coordinating a peer-to-peer review.

Strategy: Lower Priority (in terms of immediacy). Requires methodical, well-documented asynchronous communication (email, portal messages). Set reminders for follow-up.

Quadrant 4: Batch & Process

Cases: Routine PA renewals for stable chronic medications (e.g., refills for Humira); quantity limit overrides for inhalers; standard step-therapy for a non-urgent condition (e.g., dermatology cream).

Strategy: Lowest Priority. Highly efficient. These can be grouped together and processed in dedicated work blocks using templates. Minimal direct communication needed.

ADMINISTRATIVE COMPLEXITY

By mentally sorting your daily queue into these four quadrants, you create an automatic work plan. You know to tackle the “All Hands on Deck” cases first with direct phone calls, then move to the “Fast Lane” cases using efficient electronic templates, schedule time for the methodical follow-up required by “The Long Game” cases, and save the “Batch & Process” work for dedicated blocks of time when you can focus on high-volume, low-complexity tasks.

7.3.3 Mastering Prescriber Communication: The SBAR-PA Framework

Communicating with prescribers and their staff is a delicate balance of providing comprehensive information while being supremely respectful of their time. A long, rambling voicemail or a confusing message that requires them to do investigative work on their own is counterproductive. Your communication must be a model of efficiency and value. To achieve this, we will adapt the trusted SBAR (Situation, Background, Assessment, Recommendation) framework, used for decades for critical clinical communication, into a specialized tool for our purposes: the SBAR-PA.

The SBAR-PA framework provides a simple, predictable structure for every interaction, ensuring you convey all necessary information and provide a clear, actionable request in under 60 seconds.

The SBAR-PA Framework Explained
  • S
    Situation

    A single, concise sentence stating who you are, who you are calling about, and the specific subject.

    Example: “Hi, this is the PA pharmacist calling about the new prescription for Ozempic for patient Jane Doe.”

  • B
    Background

    Briefly state the results of your benefit investigation. This immediately demonstrates your value and establishes the context for your question.

    Example: “I’ve completed the insurance verification. She is covered by Express Scripts, and Ozempic is on formulary, but it requires a PA with a step-therapy requirement.”

  • A
    Assessment

    This is your analysis. State the specific gap or problem you have identified. This is the core reason for your call.

    Example: “My assessment is that we need to document a trial and failure of metformin to meet the criteria. I’ve reviewed her chart notes and medication history, and I can’t find a record of a past metformin trial.”

  • R
    Recommendation / Request

    Provide a clear, simple, and actionable recommendation or request. Ideally, this should be a closed-ended question that is easy to answer.

    Example: “My request is, can you please confirm if she has ever tried metformin in the past, and if so, can you direct me to the chart note documenting it? If not, we will need to consider starting metformin first.”

Masterclass Script Table: Applying SBAR-PA to Common Scenarios
Scenario SBAR-PA Script for EHR Message / Voicemail
Missing Step-Therapy Information

(S) This is the PA pharmacist with a question on the Jardiance for John Smith.

(B) His CVS Caremark plan covers Jardiance but requires a PA demonstrating a trial of metformin first.

(A) I have reviewed his chart and cannot locate a past trial of metformin.

(R) To proceed, please direct me to the chart note documenting a metformin trial or consider sending a new prescription for metformin per the plan’s requirements. Please advise. Thank you.
High Patient Cost-Share Identified

(S) This is the PA pharmacist regarding the Skyrizi prescription for Sarah Jones.

(B) I’ve confirmed her Cigna plan covers Skyrizi after a PA is approved.

(A) However, my assessment of her benefits shows she has a 50% coinsurance for specialty drugs, meaning her out-of-pocket cost will be over $3,000 per month until her maximum is met.

(R) My recommendation is to proceed with the clinical PA, but I also want to confirm you are aware of the high patient cost. We are initiating an application to the manufacturer’s copay program, but it may not cover the full amount. Please let me know if you would like to consider a lower-cost, preferred alternative.
Recommending a Formulary Alternative

(S) This is the PA pharmacist regarding the prescription for the non-formulary drug Latuda for Mike Davis.

(B) His OptumRx plan does not have Latuda on formulary, and a formulary exception is unlikely to be approved without trials of preferred agents.

(A) My assessment of the formulary shows that Vraylar and Caplyta are both listed as preferred, Tier 3 agents for his diagnosis and would only require a standard PA.

(R) My recommendation is to consider switching to either Vraylar or Caplyta for a higher likelihood of approval. If you would like to proceed, please send a new prescription for one of the alternatives. If you wish to continue with the Latuda exception, please provide a clinical rationale for why the preferred agents are not appropriate. Thank you.

7.3.4 Patient Communication for Financial Toxicity: The CARE Model

If communication with providers is about efficiency, communication with patients is about empathy and clarity. Patients entering the PA process are often sick, scared, and completely overwhelmed by the complexity of their insurance. A conversation about deductibles and coinsurance, if handled poorly, can cause more anxiety than the diagnosis itself. This phenomenon is known as “financial toxicity,” and your role is to be the antidote.

You must become an expert at translating “insurancese” into plain, understandable language. To structure these sensitive conversations, we will use the CARE Model. It is a four-step framework designed to Clarify the situation, Align with the patient as an advocate, introduce Resources, and Empower them with a clear plan.

The CARE Model for Financial Counseling
  • C
    Clarify

    Be transparent and direct. State the financial situation clearly and simply, using analogies to explain complex terms. Avoid jargon.

    Script: “Hi Ms. Garcia, I’m the pharmacist working on getting your new medication approved. I’ve looked at your insurance, and I want to explain the cost so there are no surprises. Your plan has something called a deductible, which is like a down payment you have to pay each year before the insurance starts covering most of the cost. For this medication, you have $800 left to pay on your deductible.”

  • A
    Align

    Acknowledge the patient’s emotional reaction (shock, fear, anger) and explicitly state that you are on their team. This builds trust and rapport.

    Script: “I know that hearing a number like $800 is a shock and can be really stressful. Please know that my only job is to help you. We are going to look at every possible option to get that number down.”

  • R
    Resource

    Immediately pivot from the problem to potential solutions. Introduce the specific resources you will explore on their behalf. This provides hope and a path forward.

    Script: “The good news is that for many expensive medications, the company that makes the drug has programs to help patients with the cost. The first thing I’m going to do is submit an application to their copay assistance program on your behalf. Very often, this can cover a large portion of that deductible.”

  • E
    Empower

    End the conversation by giving the patient a clear understanding of the next steps, a timeline, and your direct contact information. This gives them a sense of control.

    Script: “So, the next step is for me to submit this assistance application and also send the clinical information to your insurance. This usually takes a few days. I will personally call you back this Friday with an update on where we stand. In the meantime, here is my direct phone number if any questions come up. We will work through this together.”

7.3.5 Collaborating with Billing & Financial Staff: The Common Language of Codes

Your final set of key collaborators are the experts in the healthcare revenue cycle: the billing office staff, financial navigators, and reimbursement specialists. While you are the master of the pharmacy benefit, they are the masters of the medical benefit. A strong partnership with this team is essential, particularly when you are dealing with medications that are not dispensed by a pharmacy but are administered in a clinic, hospital, or infusion center. These drugs are not billed on a pharmacy claim; they are billed on a medical claim using a whole different set of codes.

Your goal in this collaboration is to align your clinical work with their financial work to ensure a “clean claim” can be submitted. A clean claim is one that has the correct service codes, the correct diagnosis codes, and a valid, matching prior authorization on file. A claim without a matching authorization will be instantly denied, forcing the hospital or clinic to either absorb the cost or bill the patient, causing immense frustration. Your common language with the billing department is the language of codes.

Key Codes to Understand When Speaking to Billing Staff:
Code Type What It Is Why It Matters to You
ICD-10 Code International Classification of Diseases, 10th Revision. This alphanumeric code represents the patient’s specific diagnosis. This is the clinical justification for the service. The ICD-10 code on the PA request must match the ICD-10 code the billing department uses on the medical claim. A mismatch will cause a denial. You must coordinate to ensure you are both using the same primary diagnosis code.
CPT / HCPCS Code Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS). These codes represent the service or item provided. For administered drugs, you’ll focus on J-codes (e.g., J9312 for Rituximab). The PA you obtain will be for a specific J-code. You must confirm with billing that they are using the exact same J-code on their claim. You also need to coordinate on the administration codes (e.g., for the IV infusion itself).
Workflow for Medically Billed Drugs (e.g., Infusions)

When you identify a drug like Remicade, Keytruda, or Reclast, your workflow must pivot to include the billing team early and often.

  1. Identification: You receive a request for an infused or injected drug. You recognize it as a medical benefit claim (“J-code drug”).
  2. Initial Payer Intel: You perform the same benefit investigation as before, but you do it on the medical payer’s portal, not the PBM’s. You are looking for their medical policy on the drug, not a pharmacy formulary.
  3. Internal Collaboration Point: This is the key step. You contact the designated financial navigator or billing specialist for that clinical area (e.g., the oncology reimbursement specialist).
  4. Code Alignment (The Huddle): You have a brief conversation to align on the details.
    The Billing Huddle Script

    You: “Hi Sarah, this is the PA pharmacist. I’m starting the authorization for a new patient, Tim Rogers, to begin Keytruda. I just want to align with you before I submit. My understanding is the primary diagnosis is metastatic melanoma, ICD-10 code C43.9. Is that the primary diagnosis you’ll be using for the claim?”

    Billing Specialist: “Yes, C43.9 is correct.”

    You: “Great. And for the drug itself, we’ll be billing the J-code J9271. Can you confirm that’s the code you need authorized?”

    Billing Specialist: “Correct, J9271. Once you get the auth, can you please send me the authorization number and the approved date range? I’ll hold the claim until I have it.”

  5. PA Submission & Communication: You submit the PA to the medical payer. Once approved, you immediately forward the approval details (auth number, dates, units) to the billing specialist. They now have what they need to submit a clean claim once the service is rendered.