What Is A Prior Authorization? A Complete Guide
- Jason Massey
- Jan 20
- 4 min read
What is a Prior Authorization?
This article provides an overview of what a prior authorization is, why it is needed, and how it can be processed to secure the needed medications and treatments.
What is a prior authorization?
A prior authorization (PA) is the process through which insurance companies determine whether a specific medication, treatment or service is covered under the policy. In other words, the insurer’s approval is required for certain prescriptions or medical procedures to be filled or undertaken.
Why Do Insurance Companies Require Prior Authorization?
1. Cost Control
The cost of healthcare is high and the insurers are eager to manage these costs in order to ensure that the treatment or medication prescribed is actually required and is not being misused. For example, they may require prior authorization for high cost medications such as GLP-1 drugs (Ozempic, Wegovy etc.) or specialty drugs.
2. Medical Necessity
Insurers want to assure that the prescribed treatment is based on evidence based guidelines. For instance, they may require documentation to show that a patient meets the criteria for a certain medication or procedure.
3. Alternatives
Many insurance companies tend to encourage the use of generic medications or low cost alternatives before covering expensive treatments. For example, the doctor may have written a prescription for a brand name drug, but the insurer may ask for proof that the patient has not responded well to a generic version.
4. Fraud Prevention
Prior authorization also helps in preventing fraudulent claims or overprescribing by requiring review by the insurance company.
These are some of the common scenarios in which prior authorization is typically required:
Medications:
Specialty or high-cost drugs (for example, GLP-1 medications like Ozempic, Wegovy or Zepbound).
Medications with high potential for misuse (e.g., Adderall, Vyvanse).
Drugs that have been prescribed for uses not approved by FDA.
Medical Procedures:
Surgeries
Imaging tests (MRI or CT scans)
Other diagnostic tools.
Durable Medical Equipment (DME):
Wheelchairs,
CPAP machines
Nebulizing equipment
Specialist Services:
Out-of-network specialists
Physical or Occupational Therapy
Mental Health Counseling
How Does the Prior Authorization Process Work?
The process of getting prior authorization consists of the following steps:
1. Prescription or Treatment Recommendation
The process is initiated when a doctor writes a prescription or recommends a treatment that needs prior authorization.
2. Submission of Documentation
The healthcare provider sends a request for prior authorization to the insurance company, which may include:
A properly completed prior authorization form.
Other supporting documentation as lab results, patient history, medication history, treatments tried & failed, etc.
3. Review of Documentation
The insurer reviews the information provided to it to determine whether the application meets the required criteria. This decision may take 24 hours or up to a few weeks.
4. Decision
Approval: The insurer approves the request and the patient may receive the treatment or medication.
Denial: The insurer denies the request or explains why the request was turned down.
5. Appeals (If Necessary)
If the request is denied, the patient or provider can appeal the decision with additional documentation or a review request.
Why the Prior Authorization Process Is So Frustrating
For many patients, prior authorizations are a source of undue stress. Here’s why:
1. Time-Consuming
The process can involve a good deal of communication between the provider and insurer, and it can slow down the patient’s access to needed treatments.
2. Lack of Transparency
Patients are often surprised when they find out that a medication or service they need requires prior authorization.
3. Administrative Burden
The submission and follow-up process for prior authorizations creates additional work for healthcare providers who already have demanding schedules.
4. Denials and Appeals
Denials are quite common and the patient may have to undergo an appeals process that can be quite lengthy.
Tips for Navigating the Prior Authorization Process
Although the process can be cumbersome, there are some tips that may help streamline it:
1. Communicate with Your Healthcare Provider
Ask your provider if the medication or treatment prescribed needs prior authorization. Providers often know what these processes are like and can ensure that the necessary documentation is submitted.
2. Understand Your Insurance Plan
Check your insurance plan’s formulary and coverage to see which treatments need prior authorization.
3. Be Proactive
If you know that a medication or procedure requires prior authorization, you should follow up with your healthcare provider and insurer to make sure that the process is moving forward.
4. Appeal Denials
If your request is denied, don’t be discouraged to try again. Many initial denials are overruled on further review.
5. Seek Professional Assistance
Services like MedBridge Concierge can help with the prior authorization process by preparing and submitting requests, following up communication with providers and insurers, and appea process management to secure timely approval of medications and treatments.
How MedBridge Concierge Can Help
At MedBridge Concierge, we know how annoying and time consuming the prior authorization process can be. That is why we are here to make it easier for you. Our team specializes in:
Submissions of prior authorization requests for medications like Ozempic, Wegovy, Zepbound, Adderall, and Vyvanse, and many others.
Handling of appeal for denied requests.
Follow up with providers and insurance companies to get approval as quickly as possible.
By delegating your prior authorization needs to us, you can focus on your health while we take care of the details.
Conclusion
While prior authorizations are a necessary part of the healthcare journey, they can be burdensome. While they are meant to ensure that treatments are necessary and cost-effective, they can create problems for patients. This article has explained how prior authorizations work and the measures that can be taken to overcome the challenges that come with them. With services like MedBridge Concierge, you don’t have to face these challenges alone.
If you are having a hard time with a prior authorization, we can help you get the care you need – fast and hassle-free. Contact MedBridge Concierge today to learn more!