All About Prior Authorization

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What is Prior Authorization?

Prior authorization is a process used by insurance companies to determine whether they will cover a specific medication or treatment. Before a patient can receive a prescription, the doctor must obtain approval from the insurer. If approved, the insurance firm provides an authorization number confirming coverage. This step helps ensure that the treatment is medically necessary according to the insurer’s guidelines.

Types of Prescriptions that Require Prior Authorization

Not all prescriptions require prior authorization, but several types often do. Common examples include:

• Specialty medications: These are high-cost drugs used to treat chronic (long lasting) diseases. These drugs are usually injected, however, can sometimes be consumed from mouth as well. The complex conditions include but are not limited to as cancer or multiple sclerosis.
• Brand-name drugs: Though all the drugs are being produced by different companies and have brand names. Some of them are known as patent drugs, these are the ones which is patented, means no other company can use this invention for a limited time period. If a generic version is available, insurers may require prior authorization for the brand-name alternative.
• Certain procedures: Some diagnostic procedures which involve testing, and surgical procedures which simply involve operation or surgery may also need approval before being performed.

The specific requirements can vary significantly between insurance plans, making it essential for healthcare providers to stay informed.

How Challenging Prior Authorization Can Be for Doctors

For many doctors, the prior authorization process can be challenging as it often involves the following:

• Time-consuming paperwork: The overall paperwork is a lengthy and tiresome process. Especially, if we talk about physicians, they are usually required to complete detailed forms and provide supporting documentation, which can be tedious and take time away from patient care.
• Delays in treatment: Prior authorization takes time and the waiting period for approval can lead to delays. This interrupts or postpones the treatment which can have bad impacts on their medication and overall health.
• Frustration: Coping up with the policies and complexities of different insurance companies can be annoying for both doctors and patients. In some cases, this may affect the doctor-patient relationship as well.

Prior Authorization Benefits for Patients and Doctors

Despite the challenges, Prior Authorization can have its benefits for healthcare specialists. Some of these include:

• Cost management: Prior authorization costs less in a manner that the prescriptions are always double checked for if there is a more cost-effective option available than can do the job. In case, doctor / healthcare specialist proves that the prescribed medication is better in terms of results only then the expensive option can be authorized.
• Encouraging evidence-based practices: Once the suggested medication goes through the authorization process. It is checked closely if this is the correct medicine for the specific problem, is there is a better solution to this medication, or if the latest research goes against this. Moreover, they also check if you have already undergone a specific test previously (in case of a valid test) and your new doctor or healthcare specialist has mistakenly asked for the same test again.

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Better Results with More Focused Practice

As a healthcare provider, your primary focus is on your patients. However, managing the complications of prior authorization and the revenue cycle can be bothersome. This is where you may need a hand of a company that can take care of complete revenue cycle management process. By partnering with professionals who specialize in revenue cycle management, you can:

• Improve efficiency: A dedicated team whose sole responsibility is to look after your prior authorization or any RCM related need can help expedite approvals and reduce delays significantly. This give your patients the experience they are looking for.
• Increase revenue: Removing the burden of complete revenue management, or just the part of it, allows you to focus more on your patient. Plus, swift approvals from the insurance companies play its own part in making the customer experience better. This expedited process increases revenue and help you expand your practice.

Conclusion

Prior authorization may involve some complexities but it also plays a crucial role in ensuring the best treatments at the best possible costs. Doctors can increase their revenue and decrease the extra load by selecting the best revenue cycle management companies in the USA.