What is Prior Authorization?
Hi, thank you for coming back for the latest edition of Beyond Primary Care’s blog- what are prior authorizations. In Beyond Primary Care blogs we highlight healthcare news, advice for medical conditions, and how membership for care works! Beyond Primary Care is an insurance free, membership based family medicine clinic. Beyond Primary Care is the highest rated Direct Primary Care clinic serving patients in Ann Arbor and throughout Washtenaw, Livingston, and Wayne counties giving families and employers peace of mind about healthcare costs by providing affordable and accessible primary care services.
The primary purpose of the blog is to introduce healthy lifestyle concepts and answer common questions we receive from patients that we believe are important. We want to start discussions that will help educate, benefit, and improve your well-being.
In this blog post, we want to educate our patients and any prospective patients about us and ways we eliminate barriers to care through understanding what prior authorizations are and how to get around them.
What is Prior Authorization?
Like every start from the ABC sitcom, The Goldbergs, it was 1980s something and all health insurers, including medicare, workers’ comp, and private insurers started to depend on utilization management approaches to contain costs. These include the physician gatekeeper programs found in HMOs, as well as prior authorization (PA) for treatment and testing.
A prior authorization is an obstruction to timely and efficient medical care. Ouch, ok- I came out swinging there. Let’s take a few steps back from how we really feel.
Hear me out though, a description of what a prior authorization is changes depending on who you ask.
Doctors and pharmacists say they take away resources (time + energy) that would otherwise be used for patient care.
Patients say it is a barrier to accessing medication and services they need.
Insurers say they are cost saving measures to find out if a medication or service is really needed.
A prior authorization is approval from an insurer before a patient can obtain a medical service or fill a prescription in order for the service / prescription to be covered by a patient’s health plan. Prior authorizations are occasionally called by other names, such as a prior auth, PA, preauthorization, precertification, prior approval, and predetermination.
Examples of Prior Authorization Barriers
“Doc, give me an example. This is still a little foreign to me.” There are tens of thousands of examples of prior authorization issues many people have faced in all branches of medicine.
Example #1 could be when the insurer requires a prior authorization for person to obtain a magnetic resonance (MR) imaging test when they can’t move their shoulder after ‘trying and failing’ a course of physical therapy.
Example #2 could be when the insurer requires a prior authorization every year for a medication a person has been on their entire life and will continue to be on for the foreseeable future.
Example #3 could be when the insurer requires a prior authorization for an CT scan for a cancer patient to rule out metastatic disease, essentially leading to a delay in chemotherapy and treatment.
Prior Authorizations Negatively Affect Practices and Patients
The prior authorization process is burdensome to physicians and aggravating to patients. According to a 2021 physician survey, the American Medical Association (AMA) found:
93% of patients experience at least some delay in receiving care due to lengthy prior authorization requests.
24% of treatment plans were often abandoned because of the prior authorization process
91% of patients perceived a negative impact on their clinical outcome
88% of physician describe the burden association with prior authorizations as high or extremely high
Given the above findings, people need to be aware that we need a more streamlined and sensitive approach to an insurers concept of managed care. Submitting a prior authorization can be time insensitive with no shortage of miscommunications.
Doctors Who Care
At Beyond Primary Care, we strive to go beyond for our patients every day, and we have the best doctors in Ann Arbor. For the longest time, we had a policy of not doing prior authorizations as we believe in a direct relationship with our patients. We work with our patient to find affordable cash pay options for services, diagnostics, and treatments that can bypass the intrusive obstruction of third party payers.
Now, when a medication or a service is inherently expensive, we have implemented a standardized response form that highlights our clinical care notes, testing, and interventions already completed. This form strongly encourages the insurers to perform their data managerial duties in order to approve our patients (their client) the services or treatments requested.
Thank you for reading.
Dr. Jeff O’Boyle with Beyond Primary Care
