Prior Authorization is something that many people have had to work with long before they become eligible for Medicare since it’s standard in group and individual health coverage.
Prior Authorization doesn’t have anything to do with healthcare, it is a cost control measure that is used to reduce improper billing and payments.
What that means for you is that by going through Prior Authorization, both you and your doctor will know before a procedure that your insurance company will pay your doctor when the bills come.
Confused about your Medicare coverage options? Watch our free video: How to Find the Best Medicare Coverage Without Paying More Than You Need To…
Is Prior Authorization evil?
Well, no. It’s not evil.
It’s a system put in place by Medicare and health insurance companies to fix a really big problem. That problem is resources not going to people who legitimately need medical care, but instead, going to criminals or just being lost through fraud, waste, and abuse.
It’s estimated that Medicare itself loses about $60 billion annually to fraud, waste, and abuse. Systems, like Prior Authorization, get put into place to make sure resources are going to where they are medically necessary.
Could the Prior Authorization process work better?
Yes, absolutely!
As of the date of this video, there is a congressional bill with strong bipartisan support that aims to do just that for Medicare beneficiaries who are in Medicare Advantage plans.
This bill focuses on transparency in the Prior Authorization process, standardizing which services need Prior Authorization across plans, streamlining the entire process, and protecting patients from any interruptions in care. If you are so moved, you can contact your Senators and member of the House and give them your opinion on the Improving Seniors’ Timely Access to Care Act.
How does Prior Authorization affect you once you’re on Medicare?
Typically, you, as the beneficiary, do not have to deal with any Prior Authorization paperwork. That’s all done by your medical provider.
Under current procedures, it can take 5 to 10 business days to find out whether a Prior Authorization request is approved or denied. However, Prior Authorization requests made electronically cuts that time by almost 70%.
Although you aren’t doing the paperwork yourself, you can certainly ask if your provider is submitting your Prior Authorization request manually or electronically and ask for electronic submission if possible.
If you are approved, treatment can go forward.
What do you do if your request was denied?
There is always an appeals process. If the first request for Prior Authorization was denied, work with your provider to find out why.
It could be something simple that can be changed or corrected on the request and resubmitted. Ninety percent of initial denials are due to insufficient documentation errors.
An audit by the U.S. Department of Health and Human Services’ Office of the Inspector General in 2018 found that Medicare Advantage plans ultimately approved 75% of requests that were originally denied.
The appeals process is there for you and your medical provider. If you use it, there’s a good chance that your request will be approved.
What if there’s a medical emergency?
Prior Authorization is never necessary in an emergency. Emergency treatment is generally viewed as medically necessary, which waives any Prior Authorization requirement.
Prior Authorization with Original Medicare and Medicare Supplements
It’s pretty unusual to need Prior Authorization for Original Medicare.
It’s rare that you would need Prior Authorization before an inpatient hospital stay under Medicare Part A, but it can happen. If it does, your doctor will need to request Prior Authorization.
Medicare Part B, your outpatient coverage, does have some situations when you may need to request Prior Authorization. The most common are coverage for durable medical equipment, frequent non-emergency ambulance transportation, and drugs covered under Part B and administered in a doctor’s office.
Because Medicare Supplements don’t make any claim decisions (they rely on Original Medicare for all claim decisions and can’t challenge Medicare claim decisions), you won’t have any Prior Authorization requirements with a Medicare Supplement.
Prior Authorization with Medicare Advantage Plans
Prior Authorization with Medicare Advantage plans is common. Requirements vary from one plan to another, but in general, any non-emergency high-cost treatment is going to have a Prior Authorization requirement.
Read your plan documents carefully so you know how Prior Authorization requirements may affect you. If you have questions about whether a particular medical service needs Prior Authorization, contact your plan directly.
As mentioned earlier, if a request for Prior Authorization is denied, do not give up!
Use the appeals process to first find out why the request was denied, and then work with your provider’s office to make any changes needed to document that the requested treatment is medically necessary for you.
Prior Authorization with Medicare Part D Plans
Prior Authorization is one of the three potential restrictions put on medications by Part D plans. The other two are Step Therapy and Quantity Limits.
Prior Authorization is used with potentially addictive medications, medications that may interact negatively with other drugs, medications that have available less expensive alternatives, and potentially protects patients from being prescribed unnecessary medications.
If you can avoid the Prior Authorization restriction by choosing a Part D plan that doesn’t have this restriction on any of your medications, that’s the easiest route to take.
If you can’t avoid a Part D Prior Authorization restriction, ask your doctor to complete the request as soon as possible. After review, the Part D plan will either approve coverage of the medication, deny coverage, or request more information from your provider.
If your request is denied, there are also appeals processes you can make use of for Part D plans.
Conclusion
Although there are good reasons for Prior Authorization, going through it can be very frustrating.
You as the beneficiary are out of the loop as your provider and Medicare or the insurance company talk amongst themselves. While you are waiting for a decision, you are also under stress waiting for medical treatment.
While there is hope that legislative changes will improve the process in the future, for now, understanding how the process works and using the appeals process to advocate for your care can make Prior Authorization less of a mystery and make it far more likely to work in your favor.
If you have questions about your Medicare coverage, feel free to give our office a call at 877-312-1414 or schedule a free, no obligation Medicare Plan Consultation.
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