Prior Authorization means the same as Pre-authorization and I’ll abbreviate it as PA.
PA is a process used by health insurance companies to control (“manage”) payment for some medications or some medical procedures (surgeries, etc.} that your doctor has prescribed or recommended.
Insurance Company or Pharmacy Benefits Manager:
“This medicine is expensive and there are cheaper medicines that are just as good.”
“This medicine is risky in some way, has certain dangers, may be addicting, and we want to be sure it is necessary.”
“We are asking your doctor to justify the prescription of the particular medicine by answering a number of questions.”
“PA is beneficial in the long run.”
“I wouldn’t have prescribed it if I didn’t think it was a good choice.”
“They already know the diagnosis and this is a standard treatment for this condition; why is PA necessary?”
“This kind of delay slows down my patient getting treatment, and I hope there is a really good reason for it which somehow benefits my patient.”
“It is a lot of extra work for everyone; the health care system has room for improvement.”
Regarding medication, PA usually leads to some, but not all, of the following:
1. Your pharmacist tries to submit a prescription for insurance coverage.
The pharmacist learns and tells you that a certain prescription will not be paid for by the insurance company until your doctor submits written evidence to the insurance company which then authorizes in advance that it will pay (PA). This evidence must answer certain questions. The pharmacist faxes a request for PA to the physician’s office. The request tells the physician which drug is involved, who to call or contact to complete the PA.
Note: It may be argued that the physician should know in advance that a PA is required and should have done the homework to take care of it in advance; or else choose to use another drug for this condition that does not require PA. Physicians and pharmacists will tell you that it can be very difficult to predict PA requirements until the pharmacist actually submits the electronic request for the medication. Insurance companies may change rules; or you may have a different insurance company with different rules.
Note: The patient can still decide to pay for the medication out of pocket, even if insurance is not covering it, and hope reimbursement will be possible down the line if it is later approved.
2. The physician’s office receives the PA request fax from the pharmacist.
Some patients are able to find out in advance that a PA will be needed, and can give the physician’s office advanced warning and who to contact.
3) The physician or office staff will contact the insurance company’s PBM (Pharmacy Benefits Manager) and answer various questions.
These questions may include:
- Patient’s name
- Insurance ID #
- Date of birth
- Patient’s address
- Reason for using this medication rather than another
- Previous medications tried
- Yes or no to whether other diagnoses are present
- Special circumstances, etc.
Sometimes this can be done in 5 or 10 minutes, using a program such as “Cover My Meds” or “Surescripts”. At other times the questions are more complex and the physician must review the patient’s chart (or even talk with the patient in person) to get necessary additional history or required information. Sometimes the PA request must be completed by a telephone conversation, after the usual waits and prompts and holds and getting the wrong or right person.
Finally, an insurance clerk asks the questions above; this can be a prolonged procedure. Allow up to 5 working days for PA to be accomplished.
4) Occasionally, after one or two denials with the above protocols, the physician will speak directly with another physician, not necessarily a specialist in the same field, and attempt to explain why in this special circumstance for this particular patient, the specific medication is justified.
We welcome questions or comments. Prior Authorization does not seem to be going away, although it is receiving a lot of complaints from both physicians and patients, and insurance companies are working to make it more effective. Perhaps e-prescribing (electronic prescribing) will allow for more efficiency and PPA (Prior Prior Authorization).