As a patient who takes control of your healthcare, it is important to know the terms and conditions around when a prior authorization is needed. The range can be significant – some health plans only require authorization for major elective medical services, while others may require an authorization for nearly any service that is non-emergent as well as many drugs.
Prior authorizations, also known as pre-certifications, are used within the healthcare industry to ensure that an insurance company has some level of control over the medical services that its members seek. And to ensure that a patient isn’t having an elective MRI every 3 months for no medical reason, or that they aren’t getting brand name prescriptions at $15,000/month when a generic at $5,000/month will do, health insurance plans build in the extra step of authorizations.
Our advice, when in doubt, is to call your health insurance plan and verify that you do or don’t need an authorization. There is typically a phone number on your insurance card dedicated to authorization questions, and especially on potentially high-dollar services, using that number could save you significant money. We also recommend that any time you call for an authorization, ask the person you talk to document the discussion in their system, and be sure to document it on your own as well. Include the number you called and the name of the health insurance employee who you spoke with.
If you do receive an authorization, it will either be given in the form of a number or a document. If a number, you will need to keep it for your records and provide it to your healthcare provider. If a document, it will likely be faxed either to you or your doctor’s office / hospital. We recommend that you have a copy on hand in case there are problems later.
Here are a few things to keep in mind about health insurance authorizations:
Authorizations and notifications are two different things. It is possible that your insurance company will want to authorize a labor and delivery, for example, but that they also will want to be notified when you enter the hospital for the event. Likewise, many health plans realize that you may not be able to get prior authorization for an urgent ER visit but may want to be notified of the visit within 24 hours.
Hospitalization authorizations will likely have a time factor to consider. On that labor and delivery, your insurance company may authorize two full days of inpatient hospitalization. If you need to go into a 3rd day, they will likely want to review the case and reauthorize if they deem it appropriate.
Your provider can help. Your healthcare provider has a vested interest in seeing you get the authorization that you need. In fact, most hospitals and many physician offices have staff to specialize in getting an authorization on your behalf. Ensure that you are working in tandem with your provider. In many cases, they will be working in the background to get the authorizations that you need (but never assume).
If your insurance company doesn’t authorize a service, it may not be over. Asking your healthcare provider to help argue your case can turnover a “no” answer, especially if your provider has a qualified nurse who is armed with medical records speak to the insurer. Similarly, if a prior authorization was not obtained, you may be able to appeal and get a “retro-authorization”, but this will most likely require a nurse and potentially a physician help clarify to the insurance carrier why the case was medically necessary.
As a physician I wholeheartedly agree with the points you made. The worst I deal with is prior auth for rehab or SNF that are denied after many days being in the hospital waiting for auth, and then the peer to peer is rejected- the patient is not safe to go home but we must discharge them home because their insurance stopped paying for them to be in the hospital days prior and our ER is full of patients boarding waiting for beds in the hospital. Then they are readmitted in a few days/weeks from complications post discharge because they did not go to rehab.
I work at an oncology practice and because we are Medicare providers, we DO accept PPO (not HMO) Advantage plans. Patients don’t need referrals from their PCP. But, that said, the biggest drawback is the prior authorization process. Patients are at the mercy of the insurance company on whether a test or treatment is approved. I’m turning 65 this year and I plan to do traditional Medicare plus a supplement, but Advantage plans can work as long as customers understand the limitations.
Medicare does require prior authorization for some outpatient services. They are services that have been among the most common sources of misuse or fraud such as certain plastic surgeries and durable medical equipment.
Still, the Medicare prior authorization list is tiny compares to Medicare Advantage plans.
I have read that more and more doctors are not accepting Medicare patients. Is this true?