Medical Prior Authorization: Everything You Need to Know

If you’ve ever had to wait for a much-needed medication or procedure, you know how frustrating it can be. You’re ready to start feeling better, but you’ve been told you need to wait for prior authorization from your insurance company. 

But what is medical prior authorization, why do you need it, and how does it work?

Insurance terms and regulations can quickly be confusing and easily become overwhelming. That’s why we’ve created this patient’s guide to medical prior authorization below.

If you feel you may need medication or treatment, it’s a good idea to understand prior authorization before heading to your doctor’s office. Keep reading for important information about medical treatment and insurance that you won’t want to miss. 

What Is Medical Prior Authorization?

Medical prior authorization, also called preauthorization, is a requirement of insurance companies for certain procedures and services. 

Prior authorization requires your hospital or doctor to get approval from your insurance company before giving you medication or performing a service. 

Insurance companies want a chance to verify that your physician’s recommendation is necessary and appropriate. In some cases, insurance companies will also want to check that there is not a less expensive option available.  

Prior authorization helps ensure that you don’t receive treatment that isn’t helpful or too expensive. In many cases, there are more affordable options available. 

If you do not receive prior authorization, your insurance company will not cover your treatment. You and your physician can appeal the decision, but it can be denied again. 

While prior authorization is intended to make sure the prescribed medication or procedure is necessary, the delays it causes have prompted criticism.

In the private insurance industry, prior authorization is an easy way for insurers to cut costs or avoid making payments. Many have also pointed out the time it takes to receive permission can cause delays in treatment. 

If you need emergency medical treatment, you do not need prior authorization. However, you may find that treatment isn’t covered later on when you are billed. 

Hows Does Medical Prior Authorization Work?

First, your hospital or doctor will prescribe you a medication or treatment. If it requires reauthorization, your doctor’s office will typically initiate the process. 

This isn’t always the case, as hospitals and providers aren’t always aware of which services require prior authorization. If you want to be sure, contact your insurer to find out if you need preauthorization. 

After your physician’s office has sent your request, it will be reviewed by your insurer. Sometimes a consultant, such as a doctor or specialist, will be included in the decision process. 

Once a decision has been reached, your insurance provider will reach out to you with approval or denial. You can appeal denied requests, but it is typically difficult to overturn the insurer’s initial decision. 

If your request is denied, your doctor may opt for medication or treatment that is less expensive in hopes of getting approval. 

How Long Does Prior Authorization Take?

Most authorization requests are completed within 3 to 10 business days. How long the process takes will depend on how promptly the request is filed and if any software is used. 

In many states, insurers have a limited amount of time to get your request decision back to you. 

Some insurance providers have varying levels of requests, with more important requests being returned more quickly. 

Why Is Medical Prior Authorization Software Important?

As you can imagine, the process of prior authorization takes time. When you need a medication or procedure, any amount of time to wait can feel like an eternity. So what software is there for prior authorization?

Prior authorization software helps speed up the process and minimize errors. With software like Exchange EDI Authorization, patients can get their requests processed far more quickly. 

Many offices still use paperwork to manage their authorization process. This increases the chances for mistakes and complications, which can slow the process or cause a denial. 

The process of filing authorization requests also takes up the valuable time of doctors and nurses. Health care offices report that they file nearly 40 prior authorization requests a week, a task that adds up to many hours of work. 

By implementing prior authorization software, this time is reduced. The less time that is spent with paperwork, the more time that can be spent treating patients. 

What Types of Services Need Prior Authorization?

Not all services require prior authorization, and it is typically reserved for the most costly procedures. Each insurance carrier and policy will have its own requirements for prior authorization.

The best way to understand what does and does not require permission from your insurance carrier is to reach out and discuss it with them. 

Typically, more expensive drugs and procedures will require prior authorization. Some common services that require prior authorization include CAT scans, MRIs, joint surgery. 

If you have been prescribed a procedure or medication that you suspect may not be covered, reach out to your insurance provider to learn more. You may also be able to discuss coverage with your physician. 

What Are Common Reasons For Denial?

Denial of prior authorization can be frustrating and even confusing. Here are some of the most common reasons your prior authorization was denied

Duplicate Service

If you have already received a service or something similar, your insurance provider may deny your request.

Other times, a service you have already had is accidentally requested. In these cases, you may be able to receive approval by resubmitting with the proper procedure listed. 

Option Is Too Expensive

If your insurance provider thinks a more affordable and comparable option is available, your request could be denied. 

When this happens, your provider may try to find another less expensive option. If the original procedure or medication is the only option, you and your provider can file an appeal.

Procedure Isn’t Necessary

Your insurance provider may deny your request if they don’t think it’s necessary. This is especially true for procedures that are cosmetic but can happen with any claim. 

Your doctor will need to provide reasons the procedure is needed in your appeal.

Errors In Filing

Many offices don’t use automated systems, meaning that there is more room for human error. Paperwork that is filed incorrectly and simple mistakes can hold up the process and cause a denial. 

If you feel that you have been denied coverage because of an error, you should reach out to your insurer and begin the appeal process. 

Treatment Option Is Too New

Treatment will only be approved if the insurance provider feels it is necessary and appropriate. This means that treatments that are new or experimental could be denied.

If your insurance company feels that your doctor has requested a treatment without enough evidence backing it, you could receive a denial. 

Treatment Isn’t Working

If you were approved for treatment once and would like to request it again, your insurer will want to know if it’s actually working.

For example, is physical therapy actually improving your condition? Has the medication you’ve been taking helped you feel better?

If not, your insurer may deny your request for the second round of treatment. While this can be frustrating, it’s also a good time to look for better options.

Who Handles the Prior Authorization Process?

Most of the time, you will not need to assist much with the prior authorization process. If you are using a provider who is in your insurer’s network, then your doctor is responsible for filing for prior authorization.  

On the other hand, you will need to intimate the process if your doctor isn’t in the network. 

In most places, it’s prohibited for your physician to charge you for the prior authorization process. If you are out of network, your insurer may be charged a fee by your provider for the prior authorization process. 

You can receive treatment without approval, but be aware that you will likely not be reimbursed for the payment. It’s always best to understand coverage before moving on with treatment. 

Patient’s Guide to Medical Prior Authorization

When you don’t feel well or need treatment, you never want to wait. The process of prior authorization can be frustrating for patients and even end in denial. 

Understanding how prior authorization works can help save you time and money during a difficult time. For more questions about what requires prior authorization, reach out to your insurance provider. 

Have more questions about medical prior authorization and its software? Reach out today to learn directly from our experts.  

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