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Dealing with prior authorization


Prior authorization should, when used, follow a uniform, automated procedure to lessen the load on doctors and health plans

Prior authorization, also known as precertification, is a healthcare plan expenditure procedure that requires doctors and other healthcare professionals to get approval ahead of time from a healthcare plan before performing a specific service on a patient to be eligible for payment coverage.

The AMA thinks there should be a significant decrease in the overall amount of healthcare services and medications requiring prior permission. Prior authorization should, when used, follow a uniform, automated procedure to lessen the load on doctors and health plans (1).

How much time does it take to get prior authorization?

Prior authorization may take between one day to as long as a month to process, based on the prior authorization request's complexity, the amount of human work required, and the payer's requirements.

According to American Medical Association, Pre Authorization Physician Study, 26% of doctors said they have waited three days or longer for a decision from insurance plans for prior authorization.

Both the clients and the healthcare personnel caring for them may have issues as a result of this delay. When challenges like delays or extra processes are added, patient compliance with medicine and therapy frequently declines.

Additionally, it steals time away from doctors and the team that assists them throughout the revenue cycle, time that would be better used for patient care.

Some individuals will seek medical treatment at an accident and emergency department as an unforeseen consequence of postponing therapy whilst the preauthorization is examined; this choice frequently results in their obtaining a sizable, unforeseen charge that is not supported by their health plan (2).

How to get a prior authorization

The pre-authorization procedure will be started by your healthcare provider if they are a part of the network.

You are in charge of obtaining prior permission if you choose to use a health professional outside of the network of your insurance plan. If you don't get it, your insurance company might not pay for the therapy or medication, or you might have to pay additional costs out of pocket.

To learn more about the procedures, services, and consumables that your particular plan calls for prior authorization for, consult your plan paperwork or give the contact number on your healthcare insurance ID card a call.

How the prior authorization process works

The pre-authorization procedure will be started by your healthcare provider if they are a part of the network.

Within five to ten working days of receiving the request from your insurance company, you should expect any of the following actions afterward:

  • Give in to your desire.
  • Turn down your request.
  • Request further details.
  • Before your initial request is granted, it is advised that you attempt a less expensive but equally effective option.

Clinical pharmacists and physicians who analyze the applications at the insurance company for the health care provided advice for these responses.

You or your healthcare practitioner may request a review of the decision if you are dissatisfied with the response you received (3).

Challenges of prior authorization

The following are the leading problems associated with prior authorization:


Many doctors have long complained about how much time they and their employees had to spend working with health insurance, according to Medical Economics.

It requires an enormous amount of administrative tasks to authorize prescriptions, including the time a doctor must spend convincing a health coverage company to pay for a drug or an expensive operation.

Expensive for the healthcare practices

Pre-authorization has long been a problem for healthcare practitioners, but little is known about the cost to specific practices or the medical system as a whole.

The requests were projected to take up, on average, 2 days per week per clinical practice in a 2009 study. This included one hour for the doctor, roughly six hours for administrative work, and 13 hours for the nurses.

Process problems

More prescription medications than ever before needing prior approval. With unique forms and policies, the array of insurance coverage is also rising. As a result, it is challenging for suppliers to stay current with the constantly evolving requirements.

Patient delay

Clients who might be delayed in receiving their prescription or therapy frequently experience the true effects of prior permission. When a patient experiences prior authorization issues, they must establish yet if the process is being held up by the physicians, the insurance provider, or the pharmacist.

Process management

The process involve in the prior authorization is sometimes complex and complicated as it sometimes may require the input of even more than one insurer (4).

How to deal with the problems of prior authorization

Healthcare providers and their teams can adopt some of the steps below to lessen the burden associated with prior authorization:

  • Find less expensive, similarly functional, and safe alternatives to any expensive medications you recommend. You won't have to endure the prior authorization procedure in this way.
  • Make master lists of prescription drugs and medical treatments, categorized by an insurer, that need prior authorization. If at all feasible, ask your staff to utilize these checklists to set up your digital medical record so that you are notified whenever you place an order for a product that needs prior authorization.
  • Employ recommendations based on evidence. For orders that depart from such suggestions, insurance companies are likely to demand prior authorization.
  • Where feasible, prescribe generic medications. Often, these do not need prior approval.
  • Communicating with patients about coverage restrictions and prior authorization is important. Patients' resentment against you for treatment refusals or delays may be lessened as a result.
  • Encourage insurers to adhere to their own prior authorization request turnaround times.
  • If your request is rejected, you can appeal. Ensure that you maintain a record of appeals and the deadline for an insurer's decision.
  • When everything else fails, fight. Some doctors send a boilerplate letter justifying their use of a certain prescription or warning against modifying a patient's pharmaceutical regimen, while some others threaten to charge the insurance for their time (5).

Hariharasudan is the CEO & founder of 24/7 Medical Billing Services, a revenue cycle management company that helps practices boost their practice performance & increase their revenue through custom billing solutions. Drop an Email to Hari here to know more


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