Prior authorization (prior auth, or PA) is a management process used by insurance companies to determine if a prescribed product or service will be covered. This means if the product or service will be paid for in full or in part. This process can be used for certain medications, procedures, or services before they are given to the patient.
Getting prior authorizations approved involves many people – primarily patients, healthcare professionals, and the patients’ health insurance companies.
When it comes to a medication prior authorization, the process typically starts with a prescriber ordering a medication for a patient. When this is received by a pharmacy, the pharmacist will be made aware of the prior authorization status of the medication. At this point, they will alert the prescriber or physician. With this notification, the physician’s office will start the prior authorization process.
They will collect the information needed for the submission of PA forms to the patient’s insurance. This can be done via automated messages, fax, secure email, or phone. In many cases, providers may need to directly call the insurance companies,
which often requires long periods of waiting—and maybe even persistent calls for a couple of days. There are high possibilities of miscommunication with the patient. Patients may not be aware of what is going on or who is involved. Additional miscommunications can happen when trying to initiate or submit the prior authorizations. These result from either pharmacists or doctors not starting the requests, fax machine malfunctioning, or having difficulties getting a person on the phone. The process can take days or weeks to get resolved with the patient having minimal information on what is happening.
The prior authorization process begins when a service prescribed by a patient’s physician is not covered by their health insurance plan. Communication between the physician’s office and the insurance company is necessary to handle the prior authorization.In order to receive approval, the prescriber may need to complete a form or contact the insurance company to explain their recommendation and the need for the particular service based on patient factors that are clinically relevant. The prior authorization is then reviewed by clinical pharmacists, physicians, or nurses at the health insurance company. Upon review, the request can either be approved or denied.
If the prior authorization was denied by the insurance company, the patient or prescriber may have the ability to ask for a review of the decision and appeal the decision.
Many physicians are not fond of the growing number of prior authorizations needed by insurance companies in recent years. A 2019 study from the American Medical Association reported that 86% of physicians believe that prior authorizations have increased in the prior 5 years.
Physicians believe that they are too time consuming and detract from time spent with patients. Some go as far as to believe that prior authorizations are purposefully put in place to “[be] burdensome so that physicians or patients will simply give up and use a cheaper alternative.”
Providers do not appreciate spending time to undertake administrative tasks like completing prior authorizations when they are not properly reimbursed for the time spent or when they do not have trained staff to expedite the process. Timothy Cordes, MD, a pediatric cardiologist, said, “[Prior authorizations] usurps the doctors’ decisions and ultimate responsibility of care, but does not compensate for the time spent. ”In a 2016 study by the Annals of Internal Medicine, it was reported that for every hour a physician spends with a patient, they have to spend an additional 2 hours on desk work.