PRIOR AUTHORIZATION PROCESS

Author: CH.Swathi

Prior authorization:

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification.

It is also called as precertification or prior approval—is a health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverages.

Prior authorization is a check run by some insurance companies or third-party payers in the United States before they will agree to cover certain prescribed medications or medical procedures.

There are a number of reasons that insurance providers require prior authorization, including age, medical necessity, the availability of a generic alternative, or checking for drug interactions.

or authorization process

Process:

The process to obtain prior authorization varies from insurer to insurer but typically involves the completion and faxing of a prior authorization form; according to a 2018 report, 88% are partial.

The medical service may be approved or rejected, or additional information may be requested.

If a service is rejected, the healthcare provider may file an appeal based on the provider’s medical review process.

• Five prior authorization challenges to consider:

1. Time-Consuming for Doctors
2. Costly for health care Practices
3. The process problem challenge
4. Patient delay
5. Process management

Origination:

Prior authorizations actually originated from the use of utilization reviews in the 1960s. Utilization reviews started at the beginning of Medicare and Medicaid legislation. Their primary use was to verify an admission in the hospital, which verified the need for treatment based on a confirmed diagnosis by two doctors.

Prior Authorization Can help by—

*Reduce the cost of expensive treatments and prescriptions by first requiring you to try a lower-cost alternative

*Avoid potentially dangerous medication combinations

*Avoid prescribed treatments and medications you may not need or those that could be addictive

Most common prescription drugs requiring pre-authorization:

Androgel

Aripiprazole

Copaxone

Crestor

The prior authorization process gives your health insurance company a chance to review how necessary a medical treatment or medication may be in treating your condition.

Procedure is most likely to need a prior authorization

In most cases, the services that require this approval are those deemed expensive or high-risk. For many carriers, the following services require prior approval: Diagnostic imaging such as MRIs, CTs and PET scans. Durable medical equipment such as wheelchairs, at-home oxygen and patient lifts.

Setting standards for prior authorization. Other current law standards regulating prior authorization are limited.The Affordable Care act prohibits use of prior authorization related to emergency care. Some states have moved to ban prior authorization for certain behavioral health care. For example, New York prohibits use of prior authorization during the first days of an inpatient admission for a mental health condition for children. Michigan recently passed a law requiring use of standardized prior authorization methods and new transparency reporting. Several states have adopted or are considering “gold card” laws that would require health plans to waive prior authorization for services ordered by providers with a track record of prior authorization approval.

Prior authorizations are required by insurance companies for some medications. This includes those that may have less expensive alternatives. The prior authorization process usually takes about 2 days.

There are several reasons a prior authorization is required. Every health insurance company uses a prior authorization requirement as a way to keep healthcare costs in check. This process will make sure that the service or drug that the physician is requesting is truly medically necessary. Requiring prior authorizations will also ensure that the service isn’t being duplicated. This is a concern when multiple specialists are involved with a single patient. And, this determines if an ongoing or recurrent service is actually helping the patient.

When a physician decides on a course of treatment for the patient that would require prior authorization (also referred to as pre-authorization), the doctor will inform the patient and their office will manage the process of putting in the request for approval to the insurance company. However, to be on the safe side, it is in the patient’s best interests to contact the insurance company themselves.

Words that no patient wants to hear when they are ready to proceed with a doctor-approved treatment plan for their medical concerns. However, it is one of the utilization management tools that insurance companies have developed to determine whether certain prescribed procedures, services, and medications are medically necessary, or whether there is an equally effective treatment available to the patient.

Outsourced service for your pre-authorizations, third-party acts as a facilitator between your practice and the payer (such as insurance companies or Medicaid). The third-party company collects patient information from your practice to obtain prior authorization for inpatient and outpatient procedures, in addition to pre-certifications for hospital admissions. An advantage of an outsourced pre-authorization service is that they have developed a centralized and streamlined process that tends to minimize any patient data errors.

An outsourcing company like Aqkode Healthcare Solutions will take care of tasks like:The end-to-end pre-authorization processAny follow-up that may be required, for example, if more information is needed from the physician for the pre-authorization.Appeals against denials where applicable.

• Pre-authorization in insurance:

When the insurer has agreed to accept the claim in advance, this stage in cashless claims process is called pre-authorization. The time taken to settle an insurance claim is an important factor for people buying health insurance

Prior authorization specialist assists patients who need treatment requiring insurance carrier pre-authorization. They interview patients to assess their medication needs and liaise with insurance companies and nurse managers for prior authorization approval.

Drugs which need prior authorization:

• Drugs that have dangerous side effects
• Drugs that are harmful when combined with other drugs
• Drugs that you should use only for certain health conditions
• Drugs that are often misused or abused
• Drugs that a doctor prescribes when less expensive drugs might work better

Impact:

• As a result of the prior authorization process, providers spend more time completing administrative duties, and patients experience delays in care. The prior authorization process harms patient access and the provider-patient relationship, which forms the foundation of trust for the healthcare system.
• Steps in the prior authorization process:
• Step #1: Your healthcare provider submits a request on your behalf.
• Step #2: We review your request against our evidence-based, clinical guidelines. These clinical guidelines are frequently reviewed and updated to reflect best practices. Your healthcare provider will communicate with us directly, and generally within 14 days or less, you and your physician will be notified of a decision.
• Step #3: At times, your request may not meet medical necessity criteria based on the review conducted by medical professionals. If this is the case, our team of medical directors is willing to speak with your healthcare provider for next steps.
• Medicare Prescription Drug (Part D) Plans very often require prior authorization to obtain coverage for certain drugs. Again, to find out plan-specific rules, contact the plan. Traditional Medicare, historically, has rarely required prior authorization
• In many states, there isn’t a uniform process or paperwork to address prior authorization requests, leading to considerable expense in both time and money for doctors, and a potential delay in treatment for patients.In an effort to achieve a more streamlined and efficient process, several states have introduced or passed legislation to create a uniform application process for prior authorization.
• For example, in 2010, in response to a request to simplify the prior authorization process, the Minnesota Department of Health produced a unified form for both prescription prior authorization and step therapy exception requests. Most notable about Minnesota’s law is a stipulation that prior authorization requests must be able to be submitted and accessed electronically by January 1, 2015. Electronic submission in conjunction with a standardized prior authorization process could increase efficiency by eliminating downtime between phone calls, faxes and standard mail.
• In many states, there isn’t a uniform process or paperwork to address prior authorization requests, leading to considerable expense in both time and money for doctors, and a potential delay in treatment for patients.In an effort to achieve a more streamlined and efficient process, several states have introduced or passed legislation to create a uniform application process for prior authorization.
• For example, in 2010, in response to a request to simplify the prior authorization process, the Minnesota Department of Health produced a unified form for both prescription prior authorization and step therapy exception requests.Most notable about Minnesota’s law is a stipulation that prior authorization requests must be able to be submitted and accessed electronically by January 1, 2015. Electronic submission in conjunction with a standardized prior authorization process could increase efficiency by eliminating downtime between phone calls, faxes and standard mail.

Prior authorizations expire:

• When your prior authorization is approved, it is approved for a limited time, usually six months or up to a year. You won’t need to submit a new request with every prescription refill. Before the prior authorization runs out, you will get an alert.