Health Care Prior Authorization: Be Prepared, Be Proactive

posted in: employee benefits

Have you ever needed an MRI or pet scan and been asked to get prior authorization? Have you ever wondered why? Or has your health insurance company ever denied you a service like an MRI or pet scan or a prescription?

Reading: Why would insurance deny an mri

Our employee benefits team hears these questions regularly as we make sure health insurance members get the most out of their plans and I’m going to try to help clear up the confusion and hopefully avoid any inconvenience. related to prior authorization for you in the future.

what is health care prior authorization?

Insurance companies often require prior authorization for services like MRIs, pet scans, and many prescription drugs. When a prior authorization is requested, it means the insurance company needs more information before making a final decision about whether you will be covered. For pet MRIs and scans, the insurance company will often have an outside provider that your doctor will have to work with to ensure that the scan, procedure, or medication is necessary and the best course of action at this time. It will be your physician’s responsibility to obtain prior authorization; however, if your doctor does not provide the information requested by the insurance company, you may be responsible for the full cost of the service or medication.

what is the purpose of prior authorization?

The main reason for prior authorization is to help control costs and prevent medical professionals from over prescribing. Ultimately, the goal is to try to prevent you, the member, and your company from continually increasing your health insurance costs each year. Due to the high costs of these services, prior authorization attempts to manage overuse of these services.

For example, CT/MRI scans may be denied because the application was incomplete and additional medical records are needed before a decision can be made. they are also often denied because medical records indicate that an x-ray may be all that is needed. the insurance company may require that a member try physical therapy before approving an MRI. We have also found that there are some doctors who will simply recommend an MRI for any pain or discomfort, although there may be a better testing option available.

What happens if you are denied prior authorization?

If your insurance company denies it, your doctor’s office will receive a fax with the reason the claim was denied and the information that will be needed for it to be reconsidered. You will also get a letter in the mail letting you know. To help speed up the process by minimizing the back and forth between your insurance company and your doctor’s office, your doctor should request a peer review instead of standard documentation. this is because it provides a telephone meeting with a medical professional. It’s important to realize that your doctor’s office plays a big role in whether or not to accept prior authorization, not just the insurance company.

As a health insurance member, you can be proactive with your doctor. be sure to check with your company’s human resources director to determine if prior authorization is needed for your insurance company, and then discuss this with your doctor.

contact us

If you still can’t get the service you and your doctor think you need, your employee benefits advisor should be able to identify exactly what’s causing the bottleneck and work to help you get the service. If you have any further questions, please contact me at [email protected]