The dual life of Prior Authorization
Prior authorization can be a little like Dr. Jekyll and Mister Hyde. There’s a good, well-intentioned side to it, and surely a necessary one at that too. On the other, it can get a bit nasty at times. A prior authorization (PA), sometimes referred to as a ‘pre-authorization’, is a requirement from the insurance company that your doctor should obtain a formal approval from your health plan before it will reimburse the cost of a specific medicine, medical device or procedure. The system has been put in place to ensure that unnecessary medical costs are avoided, overall expenses are kept under control and nothing gets prescribed that may pose a health risk to the user.
While all this sounds like coming straight from heaven, the reality of obtaining prior authorization can spell sheer hell. It usually stems from the amount of paperwork that is required to establish the ‘medical necessity’ of the prescribed medication or procedure, a critical requirement for all prior auth requests. There are also long wait times involved, and the ever looming risk of getting your prior auth request rejected due to the smallest slip or omission. It can get a little maddening at times.
Things, however, need not be so bad after all if one is willing to discover the method in the madness. Let’s take a closer look.
Making sense of Prior Authorization
Speaking of preauthorization, it is important to understand that the steps required for obtaining authorization for a specific medication or procedure will differ from another. But, there is an underlying similarity. What one should bear in mind that it’s essentially about convincing your insurance plan provider about the necessity and safety of using what has been prescribed by your doctor. Each plan is different, so while one health insurance plan may not require a PA for your treatment, another plan—even one from the same insurance company—may. Check your insurance plan policy documents before starting the process to understand if a PA is required. Also, the exact content of the PA request may vary from point to point. For example, obtaining PA for a pump may involve supplying different information than obtaining a PA for a continuous glucose monitor.
One of the best ways to ensure a smooth and uneventful prior authorization experience is to ensure that the PA request is submitted according to the plan’s guidelines. You should double-check that you meet all requirements before they are submitted. And since your doctor’s office is responsible for submitting prior auth requests, it will be important to work with your doctor, or the staff member in the doctor’s office designated to handle PAs, to ensure they have all the necessary information.
