Prior Authorization is a real necessity. Medical costs are high. Even when we have insurance, it’s important to know if insurance will cover the cost of our services.
When you receive a diagnosis that requires further testing, the last thing you want to worry about is whether or not insurance will cover it. After some research, I found an article on Very Well Health to share to help out.
Prior authorization in health care is a requirement that a healthcare provider (such as your primary care physician or a hospital) gets approval from your insurance plan before prescribing you medication or doing a medical procedure. The word “before” struck me.
Let’s think about this. Have you ever asked your doctor if they had obtained prior authorization before prescribing a medication or a procedure?
It’s important to take this step. Without prior approval, your health insurance plan may not pay for your treatment (even if it would otherwise be covered by the plan), leaving you responsible for the full bill. This is a big deal!
Image by Marijana from Pixabay
Why Are Prior Authorizations Necessary?
Bottom line, insurance companies want to determine if the specific medical service is necessary and within cost guidelines. The idea is to ensure that health care is cost-effective, safe, necessary, and appropriate for each patient. In the process of prior authorization, your insurer will make sure that certain criteria are met.
Defining Medical Necessity
Being medically necessary means that you really do need the service or drug your provider is prescribing. Insurers are looking for factors like whether the treatment is recommended for your situation according to up-to-date, research-backed evidence. They’re also checking to make sure that the service is not being duplicated.
Cost and Benefit
Insurers also want to see if it makes financial sense for you to have a service or treatment. The procedure or drug should be the most economical treatment option for your condition. *Some insurance companies suggest a “step therapy” i.e. try this first before that.
Your insurance provider needs to make sure that ongoing or recurrent service is actually helping you. Measuring your progress is done regularly during certain services. Make sure to talk to your providers often to ask how they are measuring your progress and if they have to report to insurance about your care.
Medications That Typically Require Prior Authorization
Some types of medication are more likely to require prior authorization, including:
- Drugs with serious risks (such as severe side effects)
- Drugs that carry a high risk for misuse or addiction
- Drugs that are used for cosmetic reasons not for treating a condition
- Drugs that are expensive (especially if there is a lower-cost drug available to treat the condition you have)
Services That Typically Require Prior Authorization
Examples of services that commonly require prior authorization before being approved include:
- Diagnostic imaging (such as MRIs, CTs, and PET scans)
- Durable medical equipment (such as wheelchairs)
- Rehabilitation (like physical or occupational therapy)
- Home health services (such as nurses)
- Non-emergency surgery (elective surgery)
**Check with Medicare about Medicare Parts A and B and check with your Medicare Advantage or Medigap Policy provider about their requirements ** The American Hospital Association highlights The Centers for Medicare & Medicaid Services (CMS) new regulations aimed at reforming the prior authorization process. For those on Medicare or helping people on Medicare, check this out!
Image by Paul Brennan from Pixabay
How Long Does it Take to Obtain Prior Authorization?
The current administration has proposed rules for Medicare, Medicare Advantage Plans, and ACA Marketplace Exchanges to speed up the timelines for approvals. The proposed rule would require health plans to respond within seven days to a non-urgent prior authorization request (the current requirement is within 14 days), and within 72 hours if the prior authorization request is urgent.
Health Plans each have their own rules, that’s why this gets so complicated. Talk with your physician and ask for their help. They have insurance specialists on staff. Get to know them. Take notes and call often.
In emergency situations, the need for prior authorization is often waived, and they may require retroactive authorization. It’s always best to check on this. If your insurer denies coverage, you can ask them to reconsider. Your provider’s office can let you know what steps you need to take to appeal the decision.
Communicate
Our health is precious, it is a gift. When something happens, who are the people on your team? Who are your helpers?
This is one of the most important parts of my personal contingency planning work. I urge you all to make plans and communicate those plans with your designated helpers.
The 2024 edition of my book The Living Planner (What to Prepare Now While You Are Living) is a resource for you to check out all the areas in life that require attention while we are living. Here is a direct link to my shopping cart. The Living Planner What to Prepare Now While You Are Living © Check it out HERE .
For those who seek a step-by-step DIY method: Check it out HERE. These small modules are to the point and will help you organize all areas in your life.
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“The greatest wealth is health.” –Virgil Let’s take that to heart❣️ Lynn
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