Prior Authorization is often viewed as a complex and confusing subject. It complicates the patient care process via a series of troublesome obstacles that are regularly associated with insurance policies. Dr. Amanda DeMarzo, an advocate of improving patient care outcomes via improved methods of training and education, as well as a leading figure of the National Board of Prior Authorization Specialist, breaks down the prior authorization process and demystifies the complexities of the matter.
Understanding Prior Authorization
So what is a Prior Authorization anyway? Simply put, prior authorization is a common “utilization management method” implemented by insurance companies. They allow payers to question the appropriateness of a certain medical service or treatment.
Thus, prior authorization is a fundamental tool that payers use to cut costs, and to maximize savings. Additionally, it is important to note that though the process is often associated with prescription medications, it can also be applied to billing medical services (e.g., diagnostic testing, specialists, and imaging).
The Provider Perspective
At a first glance, prior authorization sounds like a great way to reduce costs while maximizing efficiency. So, why is it often criticized? Unfortunately, physicians often deal with loads of paperwork as well as the administrative burden of the process. In many instances, providers and their staff will contribute tons of time and effort dealing with a claim. This is largely due to the fact that they have direct access to pertinent patient information that insurers need.
Furthermore, physicians and staff are not compensated for the time spent dealing with prior authorization requests, thus the incentives for completing the process without delay is often conditional and depends on the staff’s commitments to patient care. Additionally, delays in the process are favorable for payers who save money for each claim that patients turn away from.
Delays and Repercussions
Thus, prior authorizations can take days or weeks to complete, often causes nonadherence to medication and can lead to poor patient health outcomes, and do not guarantee affordable care as a claims approval only dictates whether the payer will contribute to the claim or not. Overall, it is clear that the current prior authorization process is very daunting and can hamper quality patient care.
Tips for Patients
Due to the many challenges that the prior authorization process imposes on quality care, it is equally important to educate patients on dealing with such matters. For example, if a patient has a chronic illness and requires regular treatment, it is important to inform the patient that their insurer may request reauthorization at their discretion. This can be as often as every 3 months, or as long as one year, but varies depending on the insurer and policy.
Nonetheless, a few tips that may help patients endure the lengthy process include:
- Asking your doctor which medications may need a prior authorization
- Keeping a record of approved claims or letters
- Asking your doctor if a pre-authorization can be filed to save time
- Figuring out why a claim may have been rejected so that it may be appealed
Patients Collaborating with Healthcare Providers
Patients can help navigate the prior authorization process with the help of their healthcare providers and dedicated prior authorization specialists. Prior authorizations don’t have to mean the end to care. Prior authorizations are handled effectively and efficiently with the right knowledge and skill sets.
The assistance of Ali Can, PharmD candidate 2021 is gratefully acknowledged in the preparation of this article.
The National Board of Prior Authorization Specialists (NBPAS) is an ACMA company. We focus on establishing benchmarks of excellence for the life science and healthcare industries. By specializing in minimizing prior authorization denials and improving performance, you can set yourself apart. With PACS, professionals can show their expertise in reimbursement and prior authorization.