Prior Authorizations
Picture this: you’ve just arrived at the hospital and your doctor wants to perform some necessary tests. You agree and… well that should be all there is to it, right? But you still can’t get the tests done because your insurance company says NO, you have not met the requirements for these tests. These requirements are called prior authorizations (PAs), and I’m here to help explain what they are, where we see them, and what you can do when they come up.
At their core, PAs are approvals that insurance companies require before certain medical services, procedures, or medications can be provided. They are meant to ensure the treatment is necessary and cost-effective, but they have been commonly criticized as a way for insurance companies to systematically delay or reject paying for care.
If your prior authorization request is denied, don’t give up! Here are some steps you can take:
Understand the Denial Reason: Carefully review the explanation of benefits (EOB) or the denial letter.
Submit an Appeal: Work with your provider to gather additional documentation and file an appeal.
Contact the Insurance Company: A direct conversation can sometimes clarify misunderstandings or expedite the process.
Explore Alternatives: Ask your provider about comparable treatments or medications that may not require a PA.
Did you know? Prior authorizations differ based on the type of care. For example, medical PAs involve procedures or hospital stays, while pharmacy PAs focus on medications. Therapy-related PAs (like for occupational or physical therapy) require justifications tailored to the patient's treatment goals.
The prior authorization process can be frustrating, but there are ways to make it more manageable. Providers are often experienced in dealing with insurance requirements and can help guide you. Patience, persistence, and staying informed are key.
If you’re feeling stuck, don’t hesitate to reach out! I’m here to help you navigate this process and advocate for the care you need.