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PRIOR AUTHORIZATION PROCESS, REQUIREMENTS, RULES, DIFFERENCE

Author: Mythili S ¹, Ramkumar S²

PRIOR AUTHORIZATION PROCESS

Abstract – Prior authorization in general it particularly claims the exact information from the insurer to start or to initiate the process or treatment. Without this prior approval, the health insurance plan may not pay for our treatment.Prior Authorization are commonly known as precertification, predetermination, pre approval.The prior authorization process usually requires several reasons of health insurance and these health insurance uses the prior authorization process to maintain the health cost. Each and every health plan requires the certain types of rules, regulations and some unique terms that are needed for the prior authorization. In general some of the expensive drugs and some of the expensive procedure, And some likely drugs needs this type of health plan requirements of prior authorization. Apart from these some of the drug or procedure requires only one year health prior authorization and not another process. It improve the transparency, efficiency, and immediacy. If we are need emergency medical care, most of the insurance, or most of the patients, do not requires any prior authorization process but in some of the cases they may require prior authorization process after they get a particular care after they get a particular treatment by the prior authorization. It we really wanted to get a prior authorization process from the healthcare provider, here there are some of the major steps are as follows. Prior authorization is a process by which a medical provider (or the patient, in some scenarios) must obtain approval from a patient’s health plan before moving ahead with a particular treatment, procedure, or medication. By providing and understanding the above procedure, this will help to reduce the chances of a claim denial and an unexpected medical bill. And it also helps to ensure that the medical care that we are receiving is cost-efficient and effective, stable, convenient.

OBJECTIVE – In-some cases under the medical and prescription drug plans, some of the major treatments, procedure and medications may need approval from your health insurance carrier before you receive care from the provider of health insurer.

INTRODUCTION – Prior authorization is usually claimed to require if you need a complex treatment, mitigation, Prevention or prescription. Since the maximum Coverage will not happen without the prior authorization process. And hence that was the major reason why we are beginning the prior authorization process is early important. prior authorization process has become a great source to the very well health care and it gained a great knowledge over few years (1).The need of health  insurers require prior authorization and it plays a major role in recent technology (2). In recent days they have been found that, pre-authorization requirement is a major way of rationating- health care(3). Each and every health plan requires the certain types of rules, regulations and some unique terms that are needed for the prior authorization(4). If we are need emergency medical care, most of the insurance, or most of the patients, do not requires any prior authorization process but in some of the cases they may require prior authorization process after they get a particular care after they get a particular treatment by the prior authorization(5)etc… In the year of 2010 the law of “AFFORDABLE CARE ACT “was came into the force and it mostly ensures that the patient compliance, effectiveness, compatibility and a way to control the cost(6)etc…

From This article we will be knowing what prior authorization in healthcare is? why and when health plans require prior authorization, and your options if a prior authorization request is denied by your health plan, What are the process of PAs, why do we need it and what is the difference between the pre and prior authorization

Why do we need Health Insurers required Prior Authorization process?

The prior authorization process usually requires several reasons of health insurance and these health insurance uses the prior authorization process to maintain the health cost. By using prior authorization, your insurer wants to make sure that

• Whether it is necessary for us: The service or drug we are requesting must be truly medically necessary to the customers.
• Whether it is recommended for our situation: The service of a person or drug which had been prescribed must follow up-to-date recommendations for the medical problem that we are dealing with.
• Whether it makes financial sense: The procedure or drug should be economical to the treatment for our condition. For example drug A(cheap) and drug B(expensive) is used to treat your health condition. If our healthcare person prescribes drug B (EXPENSIVE) we should think of that why drug A has not been prescribed. If we can show that Drug B is a better option, it may be pre-authorized. The main way of using drug B other than drug A is, because our health plan may refuse to use it. This was the major reason of using drug B. Most of the company insure that drug E as major concerns because of the failure attempts of drug A, since drug A does not produce any systemic response. The same concept applies to other medical procedures. For example, we can say that, our health plan may require prior authorization for an MRI so that we can make sure that a lower-cost x-ray wouldn’t be sufficient.
• Whether the service isn’t being duplicated: The major concern of this particular topic is, it involves the multiple specialist in our health care. For example, we can assume that the general doctor  had recommended us for taking scan of our uterus, without the acknowledgment of the previous report, (before one month) that we are concerned with previous gynecologist person and believes an additional scan is necessary for the upcoming process of the particular person .
•  Whether an ongoing or recurrent service is actually helping us for our health treatment- Let us consider the situation of a patient, that if a doctor as been analyzed the physical and mental therapy of that particular patient for three months, but even though the doctor has wanted to analyze the person for up- coming 3 months .whether this particular physical and mental therapy will be useful to the patient? Obviously, the additional three months will be pre-authorized. At one point if we are not taking any measures or any progress at all, or whether the physical and mental therapy was not feeling worse up to the mark, and finally our health plan will not authorize any physical and mental therapy until we speak to our health care provider, furthermore the health care provider will think about the patient why he or she was not willing for the up-coming treatment, and that will help us.
• Blue Cross and Blue Shield of Michigan list the following as the types of treatment that typically need approval are those that – The first and the for-most thing he was considered was cosmetic (example: Botox for migraine headaches) He had introduced the effective low-cost alternative drugs (such as an available generic medication)There could be some dangerous drugs and some may be in itself. There are some dangerous drug when some of the medicament are used in the combination and also it causes the serious effect on our body. Sometimes some of the drugs can be misused or abused and it used for illegal purpose . (Example: Adderall)These are some of the necessary medical conditions that has been prescribed by the Michigan. From the above list of the treatments that requires pre authorization will vary by the insurance company, if we are changing the insurance carrier we need to ensure that what are the things that are not covered .it not vary by the insurance it also caries by the requirements of the procedure.

What Are the Rules of Prior Authorization?

Each and every health plan requires the certain types of rules, regulation and some unique terms that are needed for the prior authorization. In general some of the expensive drugs and some of the expensive procedure, And some likely drugs needs this type of health plan requirements of prior authorization. Apart from these some of the drug or procedure requires only one year health prior authorization and not another process.In recent days they have been found that, pre-authorization requirement is a major way of rationing health care. If our health plan is rationing paid access process to an expensive drugs and services, it has been concluded that the people for whom the drug or the service is completely appropriate. The major concern is to ensure that the health care is almost cost-effective, safe, stable, necessary, advanced, convenient, easy and appropriate for each patient.

The Prior Authorization Rule Will Improve Efficiency, Transparency and Immediacy-Even though the prior authorization is concerned as a crucial role to the survival, but in our recent days of resources and technology has been found that it plays a major role in the patient health care and found the methodology was better to the patient.  Since the patient data was complex in nature, as it currently stands, and the patients unnecessarily pay out-of-pocket or abandon treatment and finally altogether there will be delayed in the process of PAs. But simultaneously the providers and payers both tolerate high administrative costs, reduced patient outcomes, capability, and a lack of communication, understanding, interest, collaboration, and transparency, efficiency etc.

Transparency: Let’s us consider, for example some of the provider has lack of clarity about the prescriptions, or about the benefits, coverage, and some medical policies , care guidelines, uses, pharmacological action, therapeutical activities, examples… these are some of the lack of clarities that have been affected , since the  patients had  wanted some of the care guidelines to determine the medical necessary needs and hence we are using prior authorization process for providers, on the other hand, the patients can directly able to communicate with the prior authorization persons. we can also set has a health care provider and they can clarify their doubts or any coverage or lack of clarity in the prescriptions directly to the prior authorization process and they can get a result in higher level of trust between the prayers, providers and patients.

Efficiency:  Efficiency, that majorly concerned with the ability of an information that are able to transmit by the means of an electronic device reduces the clinical reviews times, and also reduces the staff time simultaneously and ease out the burden of the medical process for the prayers.

Immediacy: when real-time decisions were rendered it was the best interest of both payers and providers. Since, immediacy of a decision was grate full to the electronic PA and it reduces the time and cost of the product, And – most importantly it has major concerned of the clinicians to the patient to provide the maximum safety, efficacy, and comfort and enabling all the necessary needs to the patients at the point of care. it has been explained in figure 1.

FIGURE 1-

What is the difference between preauthorization and prior authorization?

Almost all the pre-authorization and prior authorization has the majority of similarities but the minor difference is that the notification and prior reviews.

Whether Do We Need Prior Authorization in an Emergency?

If we are need emergency medical care, most of the insurance, or most of the patients, do not require any prior authorization process but in some of the cases they may require prior authorization process after they get a particular care after they get a particular treatment by the prior authorization.  Prior authorization usually requires a disagreement towards a patients since, the prior authorization process of treatment may be delay’s and they may be a obstacle between the patients and the care they need between the health insurance and the patients. Suppose if the patients was in on going for the treatment they may be some complex conditions like extensive treatment, or high cost of medications, or they may be a use of extensive methods, typical methods, complex methodology etc. and this may be hindrance to the patients and the process may become burden to the physicians and other staff’s who are performing the particular treatments or experiments. It has been explained in figure 3 .

How Did the ACA (Obamacare) Affect Prior Authorization?

In the year of 2010 the law of “AFFORDABLE CARE ACT “was came into the force and it mostly ensures that the patient compliance, effectiveness, compatibility and a way to control the cost. Since it completely abolish the non – grandfathered health plan process .and make the patient completely to pick their own primary care physicians. And It also prohibits health plans that requires prior authorization for an emergency care for the out-of-network hospital. Since the ACA had found that the non – grandfathered health plan process requires the internal appeal process and external appeal process which ensures in 15 days to respond a non-urgent prior authorization request. If the health care insurer denies or refuse the request, the patient can submit an appeal to the authorizer and the health care insurer has 30 days to address the appeal of the particular patient. In the Year of 2008 the Mental Health Parity and Addiction Equity Act was passed and amended that it, was expanded under the Affordable Care Act, it abolish health plans from too large or too small in comparison with something else and applying prior authorization requirements to mental health care, which was further compared with their requirements for medical benefits and surgical benefits. Many states has been implemented their own laws and ethics for the process of law that limit the length of the time of health care insurers who have to complete the prior authorization review. Additionally in some of the states, they have been introduced the electronic prior authorization process of medicaments, which are intended to make the process more efficient and affordable, faster and advantageous. Therefore, state health insurance regulations don’t apply any self-insured employer-sponsored plan since they are regulated by federal level under ERISA instead. Obamacare rules changes for 2022.

FIGURE 2-

How do we get a Prior Authorization?

It we really wanted to get a prior authorization process from the healthcare provider, here there are some of the major steps are as follows.The pictorial representation was explained in figure 2.

Firstly -Talk to Your Provider’s Office-The first and foremost thing is to start the process of prior authorization is to get the form from the providers and fill the necessary details provided by the providers. The providers will have someone to whom we have to provide the form that has been given by the providers. Once we had find out the person means then we have to move to the further needs and requirements of the procedure. If we had explained them they will ensure the necessary information if the process has been delayed they will also tell the refusal or denied of the form.

Secondly -Fill Out Paperwork-In some cases we probably will find out some of the forms that will be provided by the provider and we want to submit the request of that form which has been provided by the provider a prior authorization form will includes a major information about us as well as the medical conditions that we need and about the effectiveness, stabilities, safety and etc.. Finally it is very important to find to ensure that the completed form has recognized the information very accurately and if the information has been missing or its is been written in wrong manner it could delay our request or result is denied for prior authorization process You will probably be asked to fill out some forms that your provider’s office will use to submit the request. A prior authorization form will include information about you, as well as your medical conditions and needs.

Thirdly -Get Organized-As once you had gathered, collected and completed the paperwork as part of your prior authorization process request, and make sure that you are in track of everything that you have been collected. And then you should need to refer back to the paperwork, and further on later if the request is denied. It’s also very helpful to have a record of approved prior authorizations that you have been completed and further more if you need in case you need to request another one in the future.

Fourthly -Keep Track of Dates-There may be deadline for the prior authorization process for providing the information .and the further process is continued by the provider to submit his process or data on the submission date during the prior authorization process. The provider’s office will help keep you up to date, simultaneously it is also helpful us to set a reminder for ourselves.

Fifthly – Have a Plan If You’re Denied In case of denied authorization talk to your provider or office about the denial form. By discussing with your provider you will be able to choose to appeal the decision, if you think the prior authorization denial was not justified. The first and major step was concerned here is, If your prior authorization request is denied, find it out why? If a simple error was to blame, it might be a quick fix. After the completion of all you work and the paper was submitted then move on to the further additional information that we can able to the information and check whether any of the contents are missing and wrongly written by the mistake or any error has been occurred.

FIGURE 3-

CONCLUSION

Finally we can conclude that if our doctor recommends a particular procedure or treatment about the health care management, it’s very important to check with your health plan chart and to see if prior authorization is necessary for our health.In-case our doctor will likely submit the prior authorization request on your behalf, but it’s in your best interest to follow up and make sure that any necessary prior authorization has been obtained before moving forward with any non-emergency procedure.By providing and understanding the above procedure, this will help to reduce the chances of a claim denial and an unexpected medical bill. And it also helps to ensure that the medical care that we are receiving is cost-efficient and effective, stable, and convenient.

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