Saving Yourself from Prior Authorization Heartache!

The Struggle with Prior Authorization

Prior authorization is a unique aspect of the healthcare sector in the US, one that both elevates it to a superior quality and yet, imposes a burden upon medical practitioners and providers. It is essentially a mandate originating from insurance plans that requires doctors to obtain a formal confirmation that a prescribed medication or procedure would be covered by the patient’s health plan. The process involves, among other considerations, determining the true ‘medical necessity’ of the item for which prior authorization is being sought.

It is important to remember that insurance payers will agree to reimburse the cost only after a careful scrutiny and consideration of the actual need for the particular item. They will typically want to know why a more generic (and usually, cheaper) version of a particular medication (if such a variant is available, at all) will not work as well as the prescribed one. They will also try to verify if the new medication will have any conflict with existing medication, or is known to have any adverse side-effects.

It is evident from the above that a lot goes into the prior authorization process. In other words, when a provider is seeking it, a handful of supporting documentation needs to be provided. Denials are quite common and providers must have the tenacity and prowess to deal with them, as and when necessary. All this naturally takes away a large chunk of time and effort on the provider’s part. In fact, a recent study has shown that on an average, a week’s prior authorization can actually amount to almost 2 business days!

Tips on Saving Time and Money

One of the best ways to ensure that prior auth requests meet with fewer rejections and are granted quickly is making sure that they are submitted according to the plan’s guidelines. It makes plain good sense to double-check that all requirements are met perfectly before a request is submitted. And since the doctor’s office is responsible for submitting prior auth requests, it will be important for the patient to work closely with the doctor, or the staff member in the doctor’s office designated to handle PAs, to ensure that they have all the necessary information.

A recent trend (and a quickly growing one, too) has been to outsource prior authorization tasks to specialized, third-party billing organizations. It saves providers not just all the usual hassles associated with pursuing PA requests, but also thousands of dollars in operational cost.

Outsourcing means that there will not be any need to recruit and maintain in-house staff or pay for the overhead. Providers are required to pay only for actual hours of work done on their accounts. This is an option worth considering if you are looking to streamline your billing process, increase collections and simply find more time to spend on other important aspects of your practice, such as patient care.