Safety First: Helping Patients Understand Prior Authorization

​There's an old expression that, “It's better to ask for forgiveness than permission." But in today's healthcare world, the opposite is true—it's always better to ask for permission. The need for prior authorization for various treatments is a fact of life for almost everyone in healthcare. But while clinicians understand it, patients often don't.

Yes, doctors and other providers often grumble about the need to get preauthorization. It takes time (which no one ever has enough of) to get prior authorization for many procedures, medications, and other types of care. But providers know that it's necessary to make sure a patient's insurance company will give them the green light, so that the patient doesn't get stuck with a surprise bill.

At the same time, patients are often bewildered by the whole concept of prior authorization. They have a hazy understanding of it—they know that someone, somewhere, has to approve something before they can get the care they need or before their health insurance company will cover the cost of that care. But even then, they may question why a doctor doesn't just send them for certain tests or prescribe them a particular medication right away. 

Providers can address curiosity and even reduce any anxiety by communicating to their patients a few basic concepts about prior authorization. 

Yes, it does take time. 

It's important to be upfront about this. Be honest with your patients and acknowledge that it does take some time to get prior authorization, which can be frustrating. The time can vary, though. Remind your patients that they don't need to worry if the prior authorization doesn't occur right away. 

Not everything requires prior authorization. 

The two most common instances in which prior authorization will be required are for imaging procedures, such as CT scans and MRIs, and for brand-name prescription drugs without a generic option. If your patient requires either of those, prepare them for the likelihood of the prior-authorization process.

Patients don't have to get the prior authorization themselves. 

If your patients worry how on earth they're going to convince their health insurance companies to approve a treatment, reassure them that hospitals and healthcare facilities routinely tackle the task of obtaining prior authorization. Industry standards for electronic submission and confirmation of a prior authorization are being rolled out. Automated tools for various components of the process such as eligibility are available, and there are active industry initiatives designed to improve communication and data interchange between your doctors and authorization services. eviCore is an active participant in the development of industry standards, and we are also making enhancements to speed the provision of prior authorizations, such as fast and easy ways for providers to submit requests for prior authorization and clinical case information via the web.

Prior authorization can confirm the best method. 

Every patient deserves the best possible care, which translates into evidence-based care. The prior-authorization process can provide confirmation that only safe, effective, and appropriate treatment will be provided to the patient, based on the scientific evidence. 

Doing a little homework can be helpful. 

Let your patient know that it might be worthwhile to check out their health insurance plan's drug formularies. A patient can obtain information about their health plan's prescription drug coverage and even find out if the medications they need to take require prior authorization. Armed with that knowledge, they can communicate with their providers about what medications are covered—and which ones aren't. 

Your patients may still have questions about when and why prior authorization is needed. Make sure to let them know when you may be required to request prior authorization. It's better for them to know what's going on so they can be prepared.