Prior authorization or pre-authorization is a process that involves a patient’s physician performing a check on whether their health care plan is covering a particular service that they are asking for. This procedure is usually undertaken when dealing with expensive treatments to verify insurance services. Unfortunately, the verification process can sometimes take very long and if the requirements for confirmation are not met, the insurance provider may deny providing reimbursement for a particular treatment or access to medication.
Insurance companies have made use of certain techniques that allow them to provide medication to a larger number of people, such as quantity limits. Quantity limits are a way of making sure that a high potency drug is not prescribed over a particular limit. These standards are provided by the Federal Drug Administration. Although some physicians disagree when it comes to the standard as they come across new data, it is important to regulate medicine intake rather than have patients overdose.
Insurance companies also utilize step therapy, which roughly involves providing the patient with the cheapest treatment available and only moving toward the more expensive one if the other fails.
Benefits of Prior Authorization
Prior authorization is a very important safety precaution. According to the Academy for Managed Care Pharmacy, this process is necessary for drugs with a high potency for misuse and overdose, especially when it comes to highly addictive medication. For example, during the opioid epidemic, major pharmaceutical companies began performing prior authorization for drugs like oxycodone and morphine that cause opioid addiction.
Apart from safety, one of the biggest reasons for performing prior authorization is to make sure healthcare prices do not skyrocket. When insurance companies can confirm the details (whether the patient is utilizing an economically feasible option and the medication cannot be duplicated in the case of drugs), they can be efficient in their services as there is a level of accountability as well as cost regulation.
The Issue with Prior Authorization
However, a substantial number of physicians have objected to this system on the claim that it only saves money for insurance companies in the long run at the detriment to the health of patients. Patients making use of these services have also complained that the process is tiring, unclear and impractical for them. It also affects the quality of treatment that they were promised and impacts medical facilities negatively. Physicians have also pointed out that this entire ordeal is a waste of precious time and resources.
In this light, there are some changes that are being made to the prior authorization process. The American Medical Association or AMA shoulders the responsibility to address and resolve the issues faced by patients and physicians alike. It comprises of representatives from various health organizations, hospitals, physicians and pharmacists. As a result of this joint effort, certain headway has been made.
A number of principles have been identified as priorities for the process to amalgamate: make it more efficient and clear for all to understand, continue assisting in treatment and explore alternatives or exemptions for special cases.
Other possible solutions that have been suggested include digitalizing the verification process to speed it up, instituting proper management when it comes to logistics such as informing patients of the requirements beforehand, and institutionalizing a system of protocol to create uniformity while acquiring data. Furthermore, there is a need to deal with claim denials in a methodical fashion, i.e., provide a detailed account of why a claim was denied.