Prior Authorization - Some Updates and Quick Questions

May 31, 2018 Healthcare 0 Comments

Prior authorization has been designed as an instrument to minimize healthcare costs and control price-rise of medicines and medical equipment, wherein a pre-approval is required by the insurance company to pay its beneficiary for any medical service that they intend to avail.
Prior Authorization
Prior authorization has recently seen a minor overhaul with several regulatory and policy change implementations. Prior authorization is under rapid transformation from the manual mode to the electronic platform. This change of process has brought some complexity around prior authorizations needing adherence to stringent guidelines and additional documentation. Prior authorization has become indeed become tougher and rejections are quite a regular affair. In this scenario, much of the onus is on the professional prior authorization services who are well equipped with latest prior auth updates, knowledge of latest EHR and EMR technologies, coding expertise, etc. Although a huge number of healthcare providers still have their in-house staffs to take care of medical billing including prior authorization, they seldom match the skill of the PA professionals as they are already under immense workload handling patient care and billing operations, and not well trained owing to high training costs.
As a part of the patient-provider-payer cycle, it is important for every patient to know the basics of prior authorization. Here are a few frequently asked questions that can help minimize the gap of understanding.

How to determine if a specific treatment requires prior authorization? 

You may determine which specific codes require prior authorization by visiting the website of your insurance company. For network members, typically anything out of plan requires PA. Prior Authorization is required by some specific services so that medical affairs of the company can review the medical necessity of these services.

How to obtain a prior authorization?

A health plan member must obtain a written authorization letter from the insurance for the approval of the requested service, medicine, or procedure and give it to their provider.

Can there be additional charges for the service even after obtaining a prior authorization?
Patients even after obtaining a PA may have to pay extra as the coverage for the service might not be 100 percent. There could be other charges like copays, deductibles, co-insurance amounts, etc.
It is also advisable to know the latest update on prior authorization. Effective, January 1, 2018, prior authorization is also required for the following:
Gender Reassignment
Genetic Counseling
X-STOP Spinal Surgery
Enhanced External Counterpulsation
Chondrocyte Implants
Capsule Endoscopy
Apart from these, prior authorization requirements have been updated for Cosmetic/Dermatologic procedures and Part B Drugs. 
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