Prior Authorization Workflow Consulting — 7 Years Inside Diplomat Specialty Across Every Insurance Type

What This Service Is

AppWT consults on Prior Authorization workflows for four healthcare-buyer types where PA is a substantial operational cost center and clinical-outcome influencer:

• Specialty pharmacies — independent specialty pharmacies, hospital-affiliated specialty pharmacies, and emerging specialty-drug distribution networks where PA volume is high and approval-rate optimization directly drives revenue.
• Multi-provider high-specialty practices — oncology, neurology, immunology, rheumatology practices where in-house PA workflow consumes 20-40% of clinical-support staff time.
• Payers and PBMs — design of specialty-tier PA criteria, ePA platform selection, denial-appeal infrastructure, medical-necessity-criteria documentation.
• Pharma manufacturers — patient-assistance PA program design, REMS-program PA architecture, prescriber-certification workflow design for limited-distribution drugs.

Engagements are scoped to the specific buyer with appropriate independence-of-interest disclosures and professional separation from the founder's former employer (Diplomat Specialty / OptumRx).

The Credential

Tony Paris, AppWT's founder, spent 7 years at Diplomat Specialty corporate office in Flint, Michigan handling Prior Authorizations across the full U.S. insurance landscape. That experience covers the actual operational mechanics that strategic consultancies see only abstractly:

• Commercial PPO and HMO — Blue Cross Blue Shield variants (state-by-state plus federal employee plans), Aetna, Cigna, UnitedHealthcare, Humana Commercial, regional plans. Knows the specialty-drug benefit design, the step-therapy protocols, and the medical-necessity-criteria documentation each payer demands.
• Medicare Advantage — the major Part C carriers (Humana, Aetna, UnitedHealthcare, regional Blues plans) and how MA specialty-drug PA differs from commercial in approval thresholds, appeal timelines, and the CMS-mandated appeal-tier structure.
• Medicare Part D specialty tier — the high-cost specialty drug benefit design across Standalone Part D and MAPD, including the Tier 5 (specialty) cost-share structure, the formulary-exception process, and the Coverage Determination / Redetermination / IRE / ALJ appeal hierarchy.
• Medicaid — Michigan Medicaid plus multi-state Medicaid managed-care organizations (Molina, Centene, CareSource, regional MCOs). Knows the state-by-state Medicaid specialty-drug variation, the Federal Required DUR overlay, and the 340B Drug Pricing Program intersection where applicable.
• Tricare — military-family insurance with its specific pharmacy benefit structure including Tricare For Life, Tricare Prime, Tricare Select, and the Express Scripts-administered pharmacy benefit.
• VA — Veterans Affairs pharmacy benefit operating distinctly from civilian commercial and Medicare patterns, including the VA National Formulary and the Community Care pathway.
• Exchange-marketplace plans — ACA marketplace specialty-drug coverage variations across states, the federally-facilitated vs state-based exchange differences, and the specialty-tier cost-share variations that affect patient affordability and PA approval-likelihood.

That depth is not available from a McKinsey healthcare analyst, a ZS Associates strategy consultant, or an ePA platform vendor — it comes from 7 years of doing the work.

Prior Authorization Technology + Consulting Competition

The PA technology and consulting market has substantial competition. AppWT lists the most-frequently-cited firms here as factual reference; each operates differently and may be the appropriate choice for engagements that differ from AppWT's operational-experience specialty.

ePA Platform Vendors

• CoverMyMeds — the largest electronic-PA platform, handles a substantial share of U.S. specialty-drug PAs through prescriber-and-pharmacy-facing portals. Owned by McKesson.
• Surescripts — operates the major ePA messaging infrastructure connecting prescribers, payers, and pharmacies. Owned by RelayHealth-and-Allscripts consortium.
• Cohere Health — ePA platform with strong utilization-management focus.
• PriorAuthNow — ePA platform focused on prescriber-side workflow.
• AssureCare — PA-adjacent services for specialty pharmacies and PBMs.
• RxBenefits — PBM-and-PA-consulting services hybrid.

Strategic Healthcare Consulting Firms

• ZS Associates — major healthcare-consulting firm with PA-strategy work at payer and pharma-manufacturer level.
• Trinity Partners — pharma-and-life-sciences-focused consulting with PA-strategy and patient-services design.
• Avalere Health — payer-and-pharma consulting with specialty-pharmacy strategy practice.
• IQVIA Consulting — the consulting arm of IQVIA with substantial healthcare-data + PA-strategy capability.
• Deloitte / McKinsey / BCG / Bain (healthcare practices) — major firms with healthcare-vertical practices touching PA strategy at the enterprise scale.

AppWT does not compete with these firms on enterprise strategic engagements. AppWT operates at the operational and integration layer with $10K-$100K engagement scopes — appropriate for specialty pharmacies, mid-market practices, regional payers, and pharma-manufacturer patient-assistance programs where inside-the-pharmacy operational experience matters more than firm size or top-25-payer relationships.

Engagement Scopes (Published Tiers)

• Tier 1 — $10,000-$25,000. Single-specialty PA workflow assessment. Operational review of current PA workflow, denial-pattern analysis (sliced by payer, drug class, prescriber), payer-mix-specific criteria mapping, recommended workflow improvements with documented ROI estimate. Typical engagement duration: 4-6 weeks.
• Tier 2 — $25,000-$50,000. Multi-payer PA workflow redesign. Full redesign of PA workflow for a specialty pharmacy or multi-provider practice, ePA platform integration recommendations (vendor-neutral selection from CoverMyMeds, Surescripts, payer-specific portals), denial-appeal protocol design with timeline-aware escalation, staff-workflow documentation, and live-environment readiness review. Typical duration: 8-12 weeks.
• Tier 3 — $50,000-$80,000. REMS program PA architecture. Design of REMS-program-restricted-drug PA workflow including prescriber-certification verification, patient-enrollment integration, limited-distribution-network coordination, and FDA-Risk-Evaluation-and-Mitigation-Strategy-aware documentation. Typical duration: 12-16 weeks.
• Tier 4 — $80,000-$100,000+. Payer or pharma-manufacturer PA program design. Strategic PA program design for payers building specialty-tier PA criteria, or pharma manufacturers building patient-assistance PA programs and REMS-required prescriber-certification workflows. Typical duration: 16-24 weeks.

Frequently Asked Questions

Related AppWT Resources

• Lane D — HIPAA-Compliant Healthcare Website Design
• Lane F — HIPAA-Compliant Healthcare AI Visibility
• Lane A — Court E-Filing & EFSP Consulting (parallel structure, legal vertical)
• About Tony Paris