Dec 20th 2019

A Patient’s Story: The Personal Side of Prior Authorization

One of the healthcare system’s checks and balances is that some tests, treatments, or procedures ordered by your healthcare provider must undergo a process called prior authorization. Under this process, the request is sent to a third party to determine if it is medically necessary for your care right now, and also consistent with best practice medical guidelines.

The prior authorization process helps ensure that the treatment plan your provider requests is as effective, affordable, and medically appropriate as it should be. Think of this process as applying a “second set of eyes” that can really make a difference for you. To illustrate, we share Christina’s true story and explore one of the many ways that the prior authorization process helps to improve care from a patient’s perspective.

Christina’s Story

Living in Chicago, Christina* walked everywhere—to work, to meet friends for brunch, to exercise her yellow lab, Bentley, etc. It was during one of her routine walks with Bentley that she started to feel an unusual weakness in her body and experience blurry vision. She noticed these symptoms a few more times in the coming week, and became concerned. Christina made an appointment with her doctor to discuss the odd occurrences. The doctor told her that he’d like to run some tests.

Her Doctor’s Commitment

Christina’s doctor ordered a CT scan to take a look at her brain. The request was sent to Christina’s health insurance company, which required a prior authorization before approving the scan. As a part of the approval process, eviCore received Christina’s medical information and reviewed her insurance provider’s policy on CT scans. As it turned out, the more-expensive MRI was a more appropriate test at that time for Christina’s symptoms. As a result, the eviCore doctor offered an alternative test recommendation for a MRI instead of the CT, which was accepted by Christina’s doctor. Christina was just 22 years old. This alternative option reduced the amount of radiation that she received and provided better tissue definition to determine the cause of her discomfort. The MRI revealed that Christina had a brain tumor, so she was able to get treatment quickly, and fortunately make a full recovery.

The Tools that Providers Need

Christina’s story isn’t unique. Each day, millions of patients struggle with life-altering conditions, from musculoskeletal disorders and cancer, to heart conditions and sleep apnea. The nurses and doctors at eviCore carefully review every case received through a prior authorization request, relying on leading-edge technology, rigorous analytics, and top-quality evidence-based decision making to empower the improvement of care for health plans and patients. 

The care you receive should always be backed by the latest scientific evidence; otherwise, it can be inappropriate and expensive, and lead to other unsafe procedures and treatments. The primary mission of eviCore’s more than 400 physicians and 800 nurses is to protect your health and your wallet by making sure your care aligns with the most current evidence-based medical guidelines. To learn more, go to https://www.evicore.com/patients.

*This is a real patient story, but to maintain the patient’s privacy, names and other possible identifying details have been changed.