Breaking the Myths: What Providers get Wrong About Biologics and PA's
Jun 2, 2025
Breaking the Myths: What Providers get Wrong About Biologics and PA's
By Brianna Pepin
Biologic and specialty medications have transformed patient care across many specialties—but access remains a challenge. As biologic coordinators, we live in the world of prior authorizations (PAs), denials, step therapy, and appeals. Providers, on the other hand, just want to treat their patients quickly and effectively. And who can blame them?
But somewhere between writing the prescription and starting the medication, misunderstandings arise. Over time, these myths can create inefficiencies, delays, and frustration between providers and access teams. In this post, we’re setting the record straight by breaking down common misconceptions providers have about biologics and prior authorizations—and how we can work together to overcome them.
Myth #1: “The diagnosis is obvious—why would insurance deny it?”
Reality: Insurance doesn’t base decisions solely on the clinical validity of a diagnosis. Instead, they follow strict, plan-specific criteria to determine medical necessity, including:
Specific ICD-10 codes
Documentation of failed therapies
Step therapy compliance
Relevant labs, imaging, or test results
What seems medically obvious to a provider may still be denied without detailed documentation. Sometimes a missing sentence—like confirmation of topical failure or a reported side effect—can be the difference between approval and denial.
Myth #2: “The coordinator will take care of it all.”
Reality: Coordinators are the navigators of the process—but we’re only as effective as the documentation we receive. We can’t change notes, fabricate step therapy failures, or add missing diagnoses. We depend on providers to:
Clearly document prior treatments and outcomes
Use payer-specific language when necessary
Respond promptly to peer-to-peer requests or appeal inquiries
It takes a team effort. Behind every approval is a partnership.
Myth #3: “All biologics go through the same process.”
Reality: Nothing could be further from the truth. Each biologic has a unique access path, influenced by:
Insurance plan requirements
Pharmacy vs. medical benefit coverage
Specialty pharmacy preferences
Drug class (biosimilar vs. reference product)
Some require prior authorizations, others benefit investigations, and many go through hubs. The process is rarely uniform—and it changes constantly, especially with biosimilar expansion.
Myth #4: “Appeals don’t work—if they said no, they mean it.”
Reality: Appeals absolutely work—especially when they’re well-written and evidence-based. Many initial denials are overturned once additional information is submitted. A strong appeal typically includes:
A letter of medical necessity
Chart notes documenting contraindications or failures
Updated provider notes
Clinical evidence supporting treatment
Some of the biggest wins come from appeal persistence—especially for patients with limited options.
Myth #5: “It’s just red tape.”
Reality: It feels that way—and yes, the system can be frustrating. But behind that red tape is a process that coordinators understand and can often streamline. We know how to:
Work within the system for faster approvals
Prevent predictable denials
Connect patients with affordability programs early
Anticipate payer behaviors to minimize delays
With the right teamwork, even the most bureaucratic process can become more patient-friendly.
How We Can Partner for Better Outcomes
Breaking these myths starts with communication and collaboration. Here’s how providers can make a powerful difference:
Ask your coordinator what’s needed for a clean submission
Assume every detail may be reviewed—document accordingly
Prioritize responses to peer-to-peer or documentation requests
Trust the process—coordinators often know payer rules better than the insurer's own reps
Conclusion
Biologic coordination isn’t just a task list—it’s a strategic process. Providers bring the clinical insight. Coordinators bring the access expertise. When we understand each other’s roles and eliminate the myths, we unlock faster approvals, better outcomes, and a more empowered patient experience.
Let’s keep breaking the myths—together.
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At BC Educators, we are dedicated to empowering biologic coordinators, healthcare professionals, and patient advocates with the education, tools, and resources needed to optimize patient care. From expert-led webinars to hands-on training, we provide comprehensive support to help you navigate the ever-evolving landscape of specialty medications and prior authorizations.