What To Do If Prior Authorization Is Denied
If your request for prior authorization is denied, you may have to pay out of pocket for the full price of the drug. You may end up paying a hefty amount for a high-cost, brand-name medication. Still, you shouldnt give up without appealing the decision.
The first thing you should do if prior authorization is denied is to go through the appeals process. If your healthcare team is submitting an appeal, ask them if they need any supporting medical documents to help prove your case. If your healthcare provider can show strong evidence as to why the treatment is a medical necessity, your insurance company may approve the request.
Sometimes, a prior authorization request is denied because of clerical errors. All clinical documentation sent along with the request should be up to date with your information. Make sure to follow up with your healthcare provider so they have all the right details about your medical condition.
Your doctor may want to prescribe a low-cost alternative if the request is denied. In addition, your insurance company may require you to try other alternatives before they cover a more expensive treatment. Oftentimes, the low-cost alternative is just as effective as the high-cost treatment.
Ask your doctor to prescribe a 90-day supply or see if they can prescribe a different strength of the medication. In some cases, prior authorization depends on the days supply or dosage of the medication.
Who Is Responsible For Obtaining Prior Authorization
The healthcare provider is usually responsible for initiating prior authorization by submitting a request form to a patients insurance provider. As mentioned in the How does prior authorization work? section above, this will then often prompt a time-consuming back and forth between the provider and payer. In many cases, the licensed provider is required to sign the order, referral, or requisition before the payer will accept the authorization request.
It is also incumbent on patients to understand if preauthorization is required and if it has been approved before services are rendered.
Adhere To The Guideline Provided For Submission
Your prior authorization request may not get approved if you fail to follow the plans instruction. Accordingly, you must meet the criteria specified in the plans policy before attempting to submit the PA form. In that regard, check to see that you tick every box before they take the form for submission.
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Savings Options For When Your Insurance Company Cant Help You
If your prior authorization request is still denied and youve already tried a low-cost alternative, you can look toward other possible solutions to help you save on your medication. Ask your healthcare provider if they have free samples of the drug you need.
You can also see if there are any manufacturer coupons or savings cards that can help you save on the drug without insurance.
Patient assistance programs may help cover the cost of a drug. Check with different organizations like the Patient Access Network Foundation and Rx Outreach to see if they offer financial assistance to pay for your treatment. Contact these organizations for eligibility requirements and enrollment forms.
Another way to lower costs is to use a prescription discount card. These discount cards are usually free and easily accessible. The SingleCare discount card, for example, is free and allows you to save up to 80% off on prescription medications at participating pharmacies across the United States. You can also compare the prices of your medication across different pharmacies before you buy so you can get the lowest price.
Why Is Prior Authorization Particularly Burdensome For Diagnostics And Genomics Labs
Alternative sites of care like diagnostics and genomics labs dont usually communicate directly with patients. Instead, they are reliant on an originating provider like a hospital or physician practice to refer them business and to communicate with patients on their behalf. This business relationship, where the lab is one step removed from the patient, introduces an additional level of complexity when it comes to prior authorization.
If there is a single mistake in the prior authorization process then the diagnostics or genomics lab is put in the position of having to work through the referring provider as a go-between and to rely on them to resolve any issues with the insurance carrier. Because rendering providers depend on referrals from the originating providers, they know that they can only push the referring hospitals and physicians so hard or risk losing future business.
For a deeper dive on this subject, read: Diagnostics Lab Execs Reveal Their Biggest Revenue Cycle Challenges
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Can A Prior Authorization Decision Ever Be Overturned
If a health plan denies treatment or medication requested as part of the prior authorization process, the provider has the right to appeal on behalf of their patient.
The denial will often be communicated by phone from payer to provider first. A letter from the payer to provider will then follow. An Explanation of Benefits document will typically be sent from the payer to the patient.
The provider can then follow a formal appeals process specific to each payer. This can be a protracted, multi-step process that requires a material amount of time from providers and insurers alike.
- Level One: The initial phase begins with the doctor and patient contacting the payer to demonstrate that the requested treatment is medically necessary, and to request that the health plan re-evaluate the denial.
- Level Two: If the initial phase does not resolve the issue, the appeal is then escalated to a medical director at the carrier who has not yet been involved in the adjudication process. The medical director will evaluate whether the denial was properly assessed.
- Level Three: If the previous steps do not yield a satisfactory result for the provider and patient, the appeal may be taken to a more neutral party for review often a physician with a similar specialty as the appealing doctor, and an intermediary from the insurance company.
How Does Prior Authorization Work
How to Get Prior Authorization :
- Ask the physician how long it will take them to fill out the necessary forms.
- Check in with your pharmacy to see if the prior authorization request was approved. If it wasnt, you can see why.
Prior authorization works like this:
- Step 1: If your doctor didnt contact your insurance company when prescribing a medication, your pharmacy will contact them. They will let the physician know the insurance company requires a prior authorization.
- Step 2: The physician will contact the insurance company. They will have to fill out forms and submit a formal authorization request. You can call your physicians office and ask how long this usually takes.
- Step 3: Your insurance provider may want you to fill out and sign some forms. It would be prudent to call your insurance company and make sure there isnt anything else theyll need before reviewing the request.
- Step 4: The insurance company will alert you, your physician, or your pharmacy once they have approved or denied the request. If youre informed of the decision, contact your physician to let them know the outcome.
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How Can You See If Youll Need Prior Authorization For Prescription Drugs
There are several ways to find out if your doctor will need to get prior authorization from your insurance company. First and foremost, you could call your insurance provider directly and ask them. However, if your doctor hasnt filled out a prior authorization request, you will likely find out at your pharmacy when you try to fill or pick up the prescription.
Know The Process And Advocate For Your Health
Every insurance plan is different. Its important to know the prior authorization process so you can be prepared. If you have pre-existing conditions or rare, chronic illnesses, you should research and find an insurance plan that will cover your needs. If you have an insurance plan that has coverage tailored to your needs, youll be less likely to need prior authorization.
In any case, its good to know the prior authorization process. Medicare, Medicaid, and insurance plans usually have the guidelines and processes outlined in their documents or website. Find out how the prior authorization process works with your plan. That way, you can be empowered to be your own health advocate and get the treatment you need. There are also patient advocacy organizations like the Patient Advocate Foundation and the National Patient Advocate Foundation that can help you navigate the healthcare system.
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Why Is Prior Authorization So Complex
The prior authorization process is often complicated by a combination of factors, including:
- Lots of required steps, each introducing the potential for delays and errors.
- Participation by both payers and providers, each of whom have different motivations, workflows, and infrastructure.
- Lack of standards, particularly when it comes to payer rules.
- Fluctuating payer rules which need to be constantly monitored and revised.
- Thousands of payers and health plans.
- Manual review of prior auth requests and medical charts by clinicians.
What Does Prior Authorization Mean
Prior authorization means that your physician must follow a process to obtain prior approval from your insurance company when administering specific medications, medical devices, and medical procedures. Prior authorization must be performed before the insurance company or plan will provide full or partial coverage. Sometimes, insurance companies deny a physicians request.
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Have Your Precertification Process Managed By Experts
Some managed care programs, point of service plans, and Medicare and Medicaid require precertifications for procedures such as hospital admissions, surgeries, and some outpatient procedures. Failure to obtain preauthorization for procedures mandated by the payer can result in huge financial losses to the provider.
As your prior-authorization company, you can rest assured that all the procedures involved in the precert process will be managed efficiently. Our dedicated prior-authorization specialists will work with your office to ensure that:
- Your claims for treatments or services that require preauthorization are submitted promptly
- You have met all of the payers criteria before submitting a prior authorization request
We will ensure that precerts are submitted with the following:
- The patients insurance and demographic details
- A verbal or written order from the referring physician
- Referral from the primary care physician to the physician ordering the exam, if needed
- Detailed diagnosis, detailed clinical indications, past medical history, and the reason for the requested exam
- Number of sessions or days of inpatient status expected for hospital stays and extended care facility stays
- ICD-10 and CPT codes for diagnostic procedures and planned treatments
Our support will allow you to focus on providing timely patient care as you receive the reimbursement you deserve in quick turnaround time.
Is There A Downside To Prior Authorizations
Prior authorizations are sometimes controversial because theyre viewed by both physicians and patients as a barrier between an individual and the medical services they require. This may be especially true for anyone dealing with a chronic or complex condition that involves high-cost medications or ongoing treatments. In these cases, physicians must often repeat the pre-authorization process multiple times, which can lead to treatment delays and potentially hinder a patients recovery or progress.
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How Can Administrative Burden And Physician Abrasion Be Reduced
Healthcare providers often bristle at the idea of having to justify a prescribed treatment with insurance companies. That, in and of itself, creates friction between providers and payers.
Adding the paper chase that ensues when a prior authorization request kicks in only intensifies this friction, compounds the administrative burden that falls on the revenue cycle team, and worsens the abrasion between providers and payers. There are ways to change this scenario, however.
One of the best means to preempt the problem is to fully automate the prior authorization process so that the administrative burden of faxes, phone tag and emailing is removed, and clinicians are less likely to be consumed by the process. Prior authorization software is typically recommended.
The American Medical Association has reported that physicians spend 16 hours per week on authorizations, with almost 90% stating that authorizations delay access to care. Giving doctors back those hours to spend on patient care can improve outcomes, reduce the administrative burden and lessen abrasion with payers.
The Definitive Guide To Prior Authorization
If youre searching for an understanding of prior authorization in the medical field youve come to the right place. Just below well be outlining everything you need to know about medical prior authorization.
Prior authorization is essential for safety, cost minimization, and drug misuse management. Verified by clinical evidence, pharmacists or doctors can complete the prior authorization review process.
Gain insights into everything that prior authorization entails in this guide. Read on to learn more.
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How Does Prior Authorization Help Me
The prior authorization process can help you:
- Reduce the cost of expensive treatments and prescriptions by first requiring you to try a lower-cost alternative
- Avoid potentially dangerous medication combinations
- Avoid prescribed treatments and medications you may not need or those that could be addictive
Review your plan documents or call the number on your plan ID card for more information about the treatments, services, and supplies that require prior authorization under your specific plan.
S For Getting Prior Authorization
While each insurance provider may use slightly different steps, here is what typically happens during the prior authorization process.
Your dermatologist writes a prescription: After your prescription is sent to the pharmacy by your dermatologist or dropped off by you, the pharmacist will run the prescription through your insurance. Then, your insurance company will let either you or someone at your dermatologists office know if you need a prior authorization.What you need to know: What requires prior authorization varies from one health plan to another, so your dermatologist may be unaware that a prescription or test requires prior authorization under your plan. There are hundreds of medications and many health plans.Some health plans allow you to log in to your member account or patient portal to find out different options, such as whether your plan covers or partially covers your medication, the price, or any limits and requirements. If you learn that you need prior authorization, contact your dermatologists office as soon as possible. They have experience getting prior authorization.
Your insurance provider informs your dermatologists office of its decision. If approved or denied, the following could happen:
When your medical care requires prior authorization
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Become An Expert In Your Payers Pre
According to a study from the American Medical Association , 78 percent of physicians reported that delayed pre-authorization for physical therapy can lead patients to abandon treatment, costing therapists in private practice as much as $2.5 million in revenue each year.
A big reason many therapists fail to secure pre-authorization is because they are unfamiliar with the authorization policies of insurance providers. This is mainly due to the fact that very few health plans have similar guidelines, and pre-authorization guidelines frequently change. A study from McKesson analyzed 23 different health plans1,300 policies in totaland found only 8 percent of those policies shared common components.
It is solely up to the practice to understand the details of each plans policy, and if the proper process to obtain approval is not followed, insurers are under no obligation to pay a therapist for his or her services.
Therefore, therapists and front office staff should familiarize themselves with insurers pre-authorization policies, especially those of top payers, as these providers deliver a major source of revenue. Doing so will allow therapists to secure pre-authorization on time, ensuring patients receive the care they need and insurance reimburses therapists accordingly.
Most insurers provide regional-specific guides with a policy that details a list of services that plan offers, which services require pre-authorization, and what CPT codes, if any, must be submitted.
Request Denied Try Again
If your request for prior authorization has been denied, you have the right to know why. You can ask your healthcare provider’s office, but you might get more detailed information by asking the medical management company that denied the request in the first place.
If you dont understand the jargon theyre using, say so and ask them to explain, in plain English, why the request wasnt approved. Frequently, the reason for the denial is something you can fix.
For example, perhaps what youre requesting can only be approved after youve tried and failed a less expensive therapy first. Try it if it doesnt work, submit a new request documenting that you tried XYZ therapy and it didnt help your condition.
Or if there’s a reason you can’t do that , you and your healthcare provider can provide documentation explaining why you cannot safely comply with the insurer’s protocol.
While you have the right to appeal a prior authorization request denial, it may be easier just to submit a whole new request for the same exact thing. This is especially true if youre able to fix the problem that caused the denial of your first request.
If you and your doctor feel that an appeal is the best course of action, know that the Affordable Care Act ensures your right to an internal and external appeals process .
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Five Questions To Ask When Evaluating Prior Authorization Software
In addition to those essential features, there are a number of questions to help determine the robustness of a preauthorization system.