Prior Authorization – All You Need to Know

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Oct 27, 2022

Prior Authorization – All You Need to Know

Just imagine, you visit a doctor for an illness and you are told that you need a procedure, a medication, a test or a healthcare service. You might assume that the doctor’s recommendation or prescription serves as prior authorization for treatment. But that isn’t always the case. Sometimes approval from the insurance company is mandatory before you move forward. Simply put, you need a go ahead sign from the insurance company that the treatment is medically necessary and will be covered. Only when the insurance company says, you are good to go, the request is approved and an authorization number is sent to your physician. The insurance company may call it prior authorization, pre-authorization, prior approval, precertification or just PA. Getting approval from the insurance company for the proposed treatment or services ensures hassle-free settlement of claims.

What is the purpose of prior authorization?

The main purpose of getting a preauthorization is to keep healthcare costs under a check. The insurance company wants to make sure that the test or procedure or medication that the physician has requested is medically necessary. For instance, insurers may resist approving an expensive option if they deem it is not effective or necessary. It also ensures that a service isn’t duplicated particularly when multiple specialists are involved in providing care. It also helps to determine whether an on-going or recurring service is really benefiting the patient.

How does prior authorization work?

Getting a prior authorization basically involves the patients, the healthcare providers and the insurance companies.

In the case of a prescription that requires prior authorizations, it all starts when your doctor has prescribed something for you. You take the prescription and head to the pharmacy to collect it. Shouldn’t that be enough? Not really. If your prescription needs a prior authorization the pharmacist will notify your doctor who will in turn initiate the prior authorization process by providing the necessary information to the insurance company. It is up to the insurance company to decide whether or not to cover the medicine. Unfortunately, the insurer can also deny a prior authorization and you may end up paying out of your pocket for the medicine.

In the case of a procedure that mandates prior authorization, it all starts when you walk into a clinic and the doctor prescribes a treatment or service that is covered in your health plan. Your doctor will have to fill out and submit a pre-authorization form or approach your insurance carrier and explain the need for the service. The request can be approved or denied. In case it is denied you or your doctor can request for a review of decision or appeal this decision.

What are the treatments and medications that require prior authorization?

  1. Medications when taken together with other medications can result in dangerous interactions
  2. Medications that have the potential to cause adverse side-effects
  3. Medications that are used to treat certain specific health conditions
  4. Medications that can be commonly misused and abused
  5. Medications/treatments that have cost-effective, equally effective options available
  6. Medications that are used for cosmetic purposes, weight loss, etc.

How long does it take to get a result?

Once the prior authorization form is submitted to the insurance company they will start to review it. The time it takes for the insurance company to get a result for your prior authorization request usually varies. Some may take two to three business days while others may even take more than ten days. You can follow up with them either by calling them or sending a fax to get a status update. However, if the patient is in need of an urgent treatment or procedure, most insurance companies will allow you to file an urgent/expedited request. In such cases the insurance company will reach out to you with a decision within 72 hours.

Is prior authorization required in emergency situations?

The first priority during an emergency situation will be to save lives. Hence, procedures that have to be performed under emergency situations do not require a prior authorization. This is because when it comes to emergencies doctors will have to act quickly and provide life-saving care irrespective of the prior authorization requirements and insurance company’s policies and procedures. In fact, the Affordable Care Act bans prior authorizations for emergency services.

For doctors, prior authorization is a drain on time and resources and a distraction from providing quality care. Outsourcing prior authorization to a team of dedicated specialists can help them carry out all the paperwork related to the preauthorization process quickly and efficiently. This allows physicians to shift their focus on patient care and not paperwork related to the pre-authorization process.

If you are in need of accurate and reliable billing services get in touch with Scribe4Me today. We have a team of billing experts who understand the importance of entering correct and complete information so there are no delays or denials from the insurance company.

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