Understanding prior authorization process in healthcare industry

Prior authorization is an important checkpoint that helps minimize the chances of receiving an unexpected medical bill. It is a process through which health plans verify the care people receive is safe, effective and covered by their health plan before they undergo a procedure or surgery.

Checkpoints exist throughout the American healthcare system. They ensure people receive appropriate care and avoid preventable errors in treatment or diagnoses. While doctors and hospitals manage most of these checkpoints, health insurers also play a role. The following reasons may require a prior authorization.

• Adiagnosispresentsmultipletreatmentoptionsthatvaryin quality, outcomes and costs. For example, the procedures that used to require inpatient stays in hospitals can now take place in outpatient facilities with lower operating costs, shorter stays and sometimes better outcomes. In addition, some conditions that require surgeries may be treated with physical therapy, potentially saving the patient significant out-of-pocket costs.

• Generally accepted care guidelines have evolved. This could occur when the FDA approves the use of existing drugs to address new conditions, or when updated recommendations on the appropriate use of imaging, such as X-rays and CT scans, are issued.

• A procedure or medication comes with a high price tag.

The purpose of prior authorization in this case is to ensure the member is receiving the safest and most appropriate treatment or service according to widely accepted clinical guidelines, and that everyone is clear on what’s covered before treatment begins. Those members whose prior authorization requests are denied (less than 2%) can ask their doctor for reconsideration.

To learn more about Medicare and Medicare plans, contact licensed independent Medicare broker Sandra Teel at 681-4467135 or email Steelmanagement@gmail.com.

—Sandra Teel