Health Insurance

What Is Prior Authorization?

Prior Authorization

Visit the doctor and obtain a prescription for a new one. You might think that’s it. you need to do to get it filled at the local pharmacy, and be is covered by your health plan. But not so fast. 

Your plan might require what’s known as “prior authorization”. It means that your physician must get express authorization from your insurance provider prior to receiving treatment, treatment, or prescriptions, or else, your plan will not cover the cost.

What Is Prior Authorization? Prior Approval

Prior authorization, also referred to as precertification or prior approval is a procedure that a lot of health insurance plans must undergo before they are able to provide care.

Prior authorization is required. The doctor or healthcare professional must obtain the insurance company’s express approval for a specific procedure or drug or else the insurer will not be able to cover the cost. 

When the insurance company has received your request from the provider and it is reviewed by the company, they will either the request and either approve or deny it in a process that can take several days or even a few weeks.

Why Do You Need Prior Authorization?

Prior authorization is a controversial issue. According to insurance companies that provide health insurance they need it to avoid wasteful and unnecessary health care. According to the industry, prior approval achieves the following:

  • It prevents the use of drugs by multiple physicians — or even one doctor which, if taken together could result in dangerous negative side effects.
  • Verifies that the procedures and treatments are in line with FDA standards for the disease being treated
  • Makes sure that providers follow nationally-recognized care criteria when prescribing medications and treatments.

However, prior authorization is not without being criticized by a variety of people. 

Patients’ advocacy organizations and a lot of doctors believe that insurance companies have the power to overrule doctors and refuse the necessary medical care or medications mostly to lower costs often to the detriment of patients.

In a study conducted by the American Medical Association, 92 percent of doctors said prior authorization requirements could harm people. 

Besides ruling against the patient’s physician in some cases, the procedure also requires lengthy waiting times which can be detrimental to the patient even if an insurer later agrees with the suggested treatment.

In addition, the insurance company may deny treatment completely. The best option is to Talk to your doctor and if you and your provider are in agreement to appeal, you can follow an appeals procedure. The odds of success are about 50/50.

One study showed that 39%-59 percent of appeals led to the insurer revoking its initial coverage decision.

If the appeal is not successful If the appeal is unsuccessful, you may have to pay for treatment prescribed by your doctor in cash, which may be prohibitively costly. In addition, you might be required to collaborate with your doctor to determine alternatives.

Why Do Insurers Use Prior Authorization?

Commonly, medications that require prior authorization are:

Looking for Health Insurance?

Find Affordable Healthcare That’s Right for You

Provide a Valid ZipCode Search Now

  • Certain drugs may be dangerous when used in conjunction with other medicines;
  • Alternative medicine at lower costs is readily accessible;
  • The drugs that are frequently misused or used to treat addiction, for example, opioids
  • Prescription drugs are often used for cosmetic reasons.

Is Prior Authorization Always Needed?

Fortunately, there isn’t. If you’re faced with an emergency medical condition and require urgent medical treatment or medication the doctor may proceed without having to go through the process of prior authorization. 

However, the treatment or medication is subject to the health insurance’s emergency medical coverage, meaning insurance companies can review the decision and decide on whether it was medically required and is covered.

How Do You Know If Your Medicine Needs Prior Authorization?

To determine whether a particular treatment requires prior authorization, begin by asking your physician. Make sure to confirm this directly with your insurance provider.

Finding a prescription is much simpler. Search for the medication in the formulary of your insurance plan — which is the list of approved drugs for the plan. 

If you locate your medication in the formulary, and also the dose that is advised it is likely that your insurance plan will cover it. The formulary will indicate which prescriptions require prior authorization and which ones do require prior approval. 

If you’re not sure which side you’re on Maybe your doctor has prescribed a brand new medication or dosage that’s not on the list make contact with your insurance company and inquire if the medication is covered.

What If Your Medication Requires Prior Authorization?

If your doctor recommends an operation or medicine that requires prior authorization take these steps:

  • Check out the forms you need Then, you should be capable of downloading the prior authorization forms on the insurance company’s website.
  • Consult with your physician Your physician is the one responsible to file an authorization prior to your visit. Be sure to share the required forms with your healthcare provider.
  • Double-check the requirements: Once completed check the forms once more. Did you fill everything in? Is there anything missing?
  • Submit the forms: Your doctor’s office will send your prior authorization form to the insurance company. It could take two to three days, sometimes more until the insurer can come to an answer. 

What can happen if you don’t have prior Authorization?

When your doctor makes the request to the insurance company, they will examine the medical records. There are four possibilities for outcomes:

Approval

If your insurance provider determines that the treatment recommended is safe, necessary and possibly without a comparable alternative that is less expensive then the insurance company must be able to approve the use of the treatment. If this is the case then you and your physician are able to proceed according to the plan

Denial

If the insurer determines that the procedure isn’t medically required, that the medication is a less expensive alternative, or that the medication could interact negatively with other medications, the insurance company could deny your application for prior authorization.

If your insurance company denies you If you are denied by your insurance company, consult with your physician to discover a solution or appeal. You may also opt to pursue the treatment and reimbursement from your own funds.

Step therapy

Instead of denying you completely The insurance company could ask you and your physician to undergo what’s known as Step therapy.

Step therapy is a different method insurance companies employ to manage the cost. The most common step therapy is a three-step ladder.

Step 1

The typical first step is to try an alternative that is less expensive, such as physical therapy, instead of surgery or using a generic drug instead of a costly brand name. 

Generics that are between 80% and 88% less expensive than brand names and equally the same effects are protected and do not require any permission. 

Step 2

It is recommended to intensify the treatment or look at a different approach that is less of surgery, such as. In the case of drugs, you usually must choose an approved brand name drug that is less expensive than the generic.

Step 3

If the initial two steps aren’t enough to resolve the medical issue, will eventually receive approval to undergo the surgery or treatment that your doctor recommends. 

In the case of medications, you finally get generic medications that aren’t preferred. Remember, you’ll only be able to get to Step 3 if Steps 1 and 2 have been unsuccessful.

If your insurance provider recommends steps therapy, it will explain the steps to follow and the time you need to go through each before moving on to step. 

Limits on quantity

In some instances, an insurance company might accept a prescription and impose a limitation, for example, two pills per week for migraines. 

If your physician believes that you require a higher dosage then you must be approved prior to taking the medication to be able to take the higher dose.

Medicines that typically have dosage limitations include sleep medications migraine medications, sleep agents, and narcotic analgesics. 

Appeal

In the event that your application for medicine or treatment is rejected completely by the insurance company, You can contest the decision. In order to begin the appeal process it is necessary to write an elaborate request to the insurer. 

Make sure you include your name, the policy number, as well as your name as the insurance company in the policy. In addition, include the time of your prior authorization denial, the doctor’s name and contact details as well as the type of treatment you sought.

To increase your chances of success, ask your physician to compose a supportive letter stating why the medication or treatment is required. If appropriate, you should include the other treatments you have used previously.

If you mail your letter along with supporting documents via mail, make sure you send it by certified mail and the request for a return receipt. It is also possible to mail it via email to an appeals-specific email address. 

In no more than seven to ten days you’ll receive an acknowledgment from the insurance company that your request has been accepted. If you don’t get confirmation, you should contact your insurance provider to verify that they have all the information you provided. 

How Do You Manage the Prior Approval Process?

The process takes time and creates unnecessary stress for those who are vulnerable and sick and their overworked healthcare providers. There aren’t any solutions to that.

In order to get things moving as fast as possible, you should check with your insurance provider to determine if any new medication or treatment modification requires prior approval. 

In conjunction with your physician, complete the required forms and submit them as fast as you can. If your insurance company doesn’t answer within 3 business days, you must stop being a patient. Call your insurance provider and wait to get a response. Have fun.

Learn More