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What is Prior Authorization?
Prior authorization (prior auth, or PA) is a management process used by insurance companies to determine if a prescribed product or service will be covered. This means if the product or service will be paid for in full or in part. This process can be used for certain medications, procedures, or services before they are given to the patient.
Pre-hospitalization authorization is considered an example of
It is an example of managed care. In this, the insurer approval is firstly taken, when an insured person enters any hospital. This manages costs, and the practice is mandatory in some organizations. Pre-authorization is a certificate which determines if the requested treatment is necessary or not.
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How does Prior Authorization work?
Getting prior authorizations approved involves many people – primarily patients, healthcare professionals, and the patients’ health insurance companies.
Prescription Prior Authorization
When it comes to a medication prior authorization, the process typically starts with a prescriber ordering a medication for a patient. When this is received by a pharmacy, the pharmacist will be made aware of the prior authorization status of the medication. At this point, they will alert the prescriber or physician. With this notification, the physician’s office will start the prior authorization process. They will collect the information needed for the submission of PA forms to the patient’s insurance. This can be done via automated messages, fax, secure email, or phone.
In many cases, providers may need to directly call the insurance companies, which often requires long periods of waiting—and maybe even persistent calls for a couple of days. There are high possibilities of miscommunication with the patient. Patients may not be aware of what is going on or who is involved.
Additional miscommunications can happen when trying to initiate or submit the prior authorizations. These result from either pharmacists or doctors not starting the requests, fax machine malfunctioning, or having difficulties getting a person on the phone. The process can take days or weeks to get resolved with the patient having minimal information on what is happening.
Medical Prior Authorization
The prior authorization process begins when a service prescribed by a patient’s physician is not covered by their health insurance plan. Communication between the physician’s office and the insurance company is necessary to handle the prior authorization. In order to receive approval, the prescriber may need to complete a form or contact the insurance company to explain their recommendation and the need for the particular service based on patient factors that are clinically relevant. The prior authorization is then reviewed by clinical pharmacists, physicians, or nurses at the health insurance company.
Upon review, the request can either be approved or denied. If the prior authorization was denied by the insurance company, the patient or prescriber may have the ability to ask for a review of the decision and appeal the decision.
There are several reasons that a health insurance provider requires prior authorization. Your health insurance company uses a prior authorization requirement as a way of keeping healthcare costs in check. It wants to make sure that:
- The service or drug you’re requesting is truly medically necessary.
- The service or drug follows up-to-date recommendations for the medical problem you’re dealing with.
- The drug is the most economical treatment option available for your condition. For example, Drug C (cheap) and Drug E (expensive) both treat your condition. If your healthcare provider prescribes Drug E, your health plan may want to know why Drug C won’t work just as well. and If you can show that Drug E is a better option, it may be pre-authorized. If there’s no medical reason why Drug E was chosen over the cheaper Drug C, your health plan may refuse to authorize Drug E. Some insurance companies require step therapy in situations like this, meaning that they’ll only agree to pay for Drug E after you’ve tried Drug C with no success.
- The service isn’t being duplicated. This is a concern when multiple specialists are involved in your care. For example, your lung doctor may order a chest CT scan, not realizing that, just two weeks ago, you had a chest CT ordered by your cancer doctor. In this case, your insurer won’t pre-authorize the second scan until it makes sure that your lung doctor has seen the scan you had two weeks ago and believes an additional scan is necessary.
- An ongoing or recurrent service is actually helping you. For example, if you’ve been having physical therapy for three months and you’re requesting authorization for another three months, is the physical therapy actually helping? If you’re making slow, measurable progress, the additional three months may well be pre-authorized. If you’re not making any progress at all, or if the PT is actually making you feel worse, your health plan might not authorize any further PT sessions until it speaks with your healthcare provider to better understand why he or she thinks another three months of PT will help you.