When Do You Need Prior AuthorizationThursday, May 27th, 2010 by admin
In a perfect world, every health and prescription service you want would be covered without question, but health insurance is a huge industry and therefore it’s not easy to get a company to pay for your services. That is why a prior authorization is sometimes needed for many services. Understanding how can save you time and frustration.
Policy providers understand that some services have to be covered. Check ups, basic antibiotics, and x-rays should be covered without question. But other services and drugs are not so easily covered.
If a doctor orders a test for a patient that is outside the normal protocol, an insurance company may want the doctor to get the test approved before they will pay for it. Let’s say, for instance, a doctor wants to order a colonoscopy for a patient who is in their early twenties. The policy provider might find this to be unnecessary for a person that age. So before the doctor does the test, the insurance company will want to talk with him about it.
When the insurance company requires a prior authorization, they are simply asking that the doctor call them and discuss the need for the procedure that is being done. In the case of the colonoscopy, the insurance may want to know what criteria the patient meets to justify the test.
The same thing goes for insurance coverage on prescription drugs. Medications are put into a category that pre-determines the amount a patient will pay or the ability they have to purchase the drug. However, there are some drugs that require a prior authorization.
There are generally two reasons that drugs may require prior authorization. The first is the drug is not generally used for a patient’s age. If a patient were to get an acne cream at the age of six, then the insurance coverage may not be applicable for that drug. The second reason is that a specific drug may not be cost effective for the insurance company.
In this case, a doctor will have to call up and speak to the policy provider about what criteria that patient meets to warrant such an expensive or unusual drug.
Just like with the test, insurance coverage does not guarantee that all services will be covered. A doctor may plead a patient’s case and still be denied coverage by the company. At that point it is up to the doctor and the patient to determine if other services should be considered or if the procedure is cost effective for the patient.
Insurance coverage does its best to ensure that you are taken care of, and sometimes to ensure that, prior authorization is needed.