Most health plans require patients to get an approval, called prior authorization, for certain kinds of medications, tests, procedures, or treatments.
Sooner or later, you will likely need to get your insurer’s prior authorization for a health care service. Understanding the basics of this process will help you work with your doctor or hospital to navigate holdups and advocate for the health care you need.
1) Why do insurers require prior authorization?
Insurers use prior authorization to make sure patients’ health care is necessary and appropriate. In theory, that helps to protect patients and control costs.
2) How does this practice affect patients and providers?
Prior authorization requirements can sometimes lead to delays or denials for care. These roadblocks cause frustration and worry for doctors, hospitals, and patients while adding to the mountain of paperwork doctors and hospitals must do.
According to the American Medical Association’s (AMA) 2017 survey, about one in four doctors said the need to obtain prior authorization led to serious harm for at least one of their patients. One in three doctors surveyed have staff who work only on prior authorizations. Doing that extra paperwork can cost thousands of dollars a year.
In some cases, prior authorizations can be changed or revoked after patients receive care they thought was approved.
During surgery, for example, your surgeon and care team will do what’s needed to give you the best possible results. That may mean providing medical care that’s necessary, but different from what was previously authorized. As a result, your insurer could refuse to cover you or pay providers for some or all of your care.
3) How do I know if I need to get prior authorization?
Your health plan can tell you. In general, insurers require prior authorization for treatments that are some combination of new or experimental, expensive, complicated, or having very uncertain or unknown outcomes.
Your doctor or hospital will do their best to tell you if you need prior authorization. However, with so many different health plans on the market and the ever-advancing nature of medical care, it’s best to ask both your provider and your insurer about any treatment, including medication, that may be complex or expensive.
4) Who is responsible for getting the authorization?
In most cases, the doctor’s office or hospital where the prescription, test, or treatment was ordered is responsible for managing the paperwork that provides insurers with the clinical information they need.
You should stay on top of this process and reach out to your insurer and provider as needed. When you call your insurer, ask who specifically will make the decision. Most insurers contract this work out to benefits-management companies. Find out who that is and reach out directly to the clinical reviewer.
5) How long does prior authorization take?
That depends on the nature of the request and the policies of your insurer or health plan. I’ve seen some guidelines that promise 24-hour turnaround for urgently needed medications (if all the paperwork is submitted correctly). Other insurers refer to “five-to-ten” days for a decision. Physicians in the AMA survey said that turnaround varies from one business day to five or more.
It’s especially important for insurers to be able to process prior authorization requests on weekends and after normal business hours during the week.
I know of one case where a 90-year-old patient with severe back pain urgently needed surgery that required prior authorization. Unfortunately, the insurer had a 14-day window to decide. While waiting, the patient had to go to the emergency room for pain control — adding stress and expense to an already difficult and deteriorating medical situation.
6) What if my authorization is denied?
Does your provider know why the request was denied? Find out the precise reasons for the denial and how your provider will address these in the appeal. Other next steps may include:
Reaching out to the human-resources department at your job and asking them to talk to the insurer.
Checking in on how the provider is doing with the appeals process.
Asking whether your provider has reached out to the insurer’s medical director for a doctor-to-doctor conversation about why the test or treatment is needed.
7) Pennsylvania doctors and hospitals are asking for reforms
Doctors and hospitals say they are handling more requests for prior authorization. Delays and denials are becoming more common. Providers would like to see common sense protections that require insurers to:
Make timely decisions, especially after business hours and on weekends.
Cover and pay claims for care that could not be pre-authorized because it became necessary during the course of a pre-authorized test, treatment, or procedure.
Share prior-authorization approval and denial rates for Pennsylvania on their websites.
Until reforms are enacted, it is important that you, the patient, keep on top of the prior authorization needed for your care. The last thing you need after a major medical procedure is to find out that your insurer won’t cover it.
Andy Carter is president and CEO of The Hospital and Healthsystem Association of Pennsylvania, and a member of the Inquirer’s Health Advisory Panel.