Changing jobs often means changing medical insurance coverage providers too. If youâre a patient with a pre-existing condition, chances are you and your doctor will have to go through the process of prior authorization to continue certain medications, procedures, or therapies. Prior authorization is a method used by some health insurance companies to determine if they will cover theses prescribed procedures, services, or medications. Without following this procedure, your insurance provider may not provide coverage, or pay for medications or operation, leaving you to cover some, or all, of the costs out of your own pocket. Intended to prevent over utilization and to control costs, prior authorization has been a go-to tool for insurance companies for years. However, many disagree, feeling the process is ineffective, actually increases costs and, creates an over utilization of resources.
From medications, therapies, and surgeries, healthcare can be quite expensive. As the case in any business, controlling costs and efficiently managing resources is a top priority, which is no different for insurance companies. Using prior authorization, they use this strategy in verifying that other therapies (which coincidently are often much cheaper) have been tried and proven unsuccessful. Requiring proof that healthcare providers previously tried conventional regimens to treat their patientsâ conditions are requested in the form of prior medical records, prescription histories, office visit notes, and procedural documentation are a few of the items used to approve or deny items being requested by prescribing clinicians. While the process seems simple enough, it can be quite complexâŠespecially for those on the other side of the fence, most notably physicians and patients.
For physicians, their profession is far more than just seeing and treating patients. It means running a business as well, which involves expense management such as labor, supplies, rent, and taxes to ensure their practice is successfulâŠboth clinically and financially. From the physicianâs perspective, prior authorization is far from a cost savings tool, but rather a myriad of additional costs. One of the most notable is the time and resource drain all too often experienced by way of the phone calls, collection of records, faxing, mailing, and follow ups that are necessary to appease the insurance company requirements for prior authorization. The process itself tends to over-tedious through a barrage of delays resulting from reviews, initial denials, appeals, peer to peer discussions, and even involving other independent reviewers to help make a final determination of approval or denial. The adage of âtime is moneyâ is never truer than what physicians experience in dealing with prior authorization. The unfortunate reality is the additional time being spent is costing them a tremendous amount of money to proveâŠor even re-proveâŠtheir decisions are validated.
And letâs not forget the patient. Itâs mostly the patients suffering the greatest in the prior authorization process. Letâs take those diagnosed with an autoimmune disease, such as Crohnâs Disease, whose been taking a biologic medication (such as Humira) for several years as an example. Like other medications, this is a time-sensitive therapy whereas it needs to be taken on a very scheduled dosing pattern to keep and maintain patients in remission from disease. Even a delay of 7 to 10 days, as the prior authorization process evolves, can cause doses being missed and conditions to become worse. Initial denials and subsequent appeal reviews can add an additional 30-plus days before the medication is finally approved. In these cases, several doses are missed leading to more intensive medical intervention by way of hospitalizations, additional medications, or even surgery to address the exacerbation of the disease.
Bottom line, while prior authorization may have its benefits, these are almost exclusively seen on the insurance companiesâ end. Itâs far from being the ideal system in managing costs, abuse, misuse, or over utilization for the healthcare system as a whole. Unfortunately, the delays in approving prescribed therapies can lead to conditions and diseases manifesting into more acute or critical issues and thus, leading to more costly procedures or treatments which are necessary to address them. As a patient, even if you havenât yet experienced prior authorization yet, itâs important to do your homework and understand how it works. Make sure you have access to your medical records, stay in close communication with all of your healthcare providers, and donât settle for less than you need to make certain your care is right for you.