Prior Authorization: Discover Why it Matters for You

Have you ever heard the terms preauthorization, preapproval, or precertification during a visit to your doctor’s office?

These words are used interchangeably to refer to an approval process, usually called prior authorization. Most health plans require patients to get approval, called prior authorization, for certain kinds of medications, tests, procedures, or treatments.

Sooner or later, you will likely need to get your insurer’s prior authorization for a health care service. Understanding the basics of this process will help you work with your doctor or hospital to navigate holdups and advocate for the health care you need. 

1)   What exactly is the prior authorization process?

If your physician prescribes a drug, procedure, or test that needs prior approval, the office will submit a formal request to your insurance company.[1] The insurance company will then review the request and issue a decision.

Note, however, that receiving prior approval does not guarantee that your insurance will cover all of your treatment costs.[2]

2)   How long does prior authorization take? 

That depends on the nature of the request and the policies of your insurer or health plan. Some guidelines promise 24-hour turnaround for urgently needed medications (if all the paperwork is submitted correctly). Other insurers refer to “five-to-ten” days for a decision.

It’s especially important for insurers to be able to process prior authorization requests on weekends and after normal business hours during the week. 

3)   What if a prior authorization decision is taking a long time? What if the request is denied?

Prior authorization requirements can sometimes lead to delays or denials for care. These roadblocks cause frustration and worry for doctors, hospitals, and patients while adding to the mountain of paperwork doctors and hospitals must do.

If a prior authorization request for needed health care is denied, don’t give up. Find out whether your doctor knows exactly why the request was denied and what the plan for appeal is.

In some cases, prior authorizations are changed or revoked after patients receive care they thought was approved.

During surgery, for example, the surgeon and care team will do what’s needed to achieve the best possible results. That may mean providing medical care that’s necessary—but different from what was previously authorized. As a result, the insurer could refuse to cover the patient’s care or pay the doctor or hospital.

4)   When is prior authorization required?

In general, insurers require prior authorization for treatments that are some combination of new or experimental, expensive, complicated, or with very uncertain or unknown outcomes.

Your doctor or hospital will do their best to tell you if you need prior authorization for the care being prescribed. However, with so many different health plans on the market and the ever-advancing nature of medical care, it’s best to ask both your provider and your insurer about treatment, including medication, that’s complex or expensive.

5)   Why do insurers require prior authorization?

Insurers use prior authorization to make sure patients’ health care is necessary and appropriate. In theory, that helps to protect patients and control costs.

Unfortunately, doctors say that:

  •       Prior authorization requirements are increasing
  •       Delays in getting approvals and denials are affecting the quality of patients’ care
  •       The resulting extra paperwork and phone calls are adding to the cost of health care

6)   Do we need prior authorization reforms?

A coalition of 33 different health care groups—including those representing doctors, hospitals, and patients—is asking for commonsense protections that require insurers to:

  •       Make timely prior authorization decisions, especially after business hours and on weekends
  •       Cover and pay claims for care that could not be pre-authorized because it became necessary during the course of a pre-authorized test, treatment, or procedure
  •       Share prior-authorization approval and denial rates for Pennsylvania on their websites

To learn more about important health care issues—like prior authorization—that impact you, be sure to sign up for our Pulse on Policy email: https://signup.healthymepa.com/policy