Health insurance companies have been using prior authorization for different types of treatments and prescription drugs for many years. And the intention behind this process is to ensure patients receive medically necessary and appropriate treatments.For an insurance company, it’s also important to ensure that doctors prescribe medications that are covered by the health plan.
But as with all such well-intended processes, there are downsides that come with having to go through a prior approval system for drugs being prescribed.
And understanding the true effects of the process should be enough incentive to streamline it as much as possible.
What Medications Require Prior Authorization?
There are two main types of drugs that a typical insurance company will require prior authorization for. Both situations usually involve expensive drugs, with some of them often newly licensed.
First of all, there are many expensive drugs that are no longer protected by patents. And that often means that cheaper generic brands are able to create the same drugs and offer them at much more competitive prices.
Insurance companies often require prior authorizations for such drugs to ensure that doctors prescribe the cheaper options that deliver the same results.
Secondly, there are some new drugs that are either not yet covered by insurance companies, or there are alternative treatments that may be just as suitable at a lower cost.
In both these situations, prior authorization will ensure that doctors consider every alternative option and that patients don’t end up out of pocket when they have to cover the costs of drugs that their insurer doesn’t cover.
But there are other situations where the health care system has identified certain situations that require careful monitoring under health plans.
- High long-term costs for chronic diseases like heart disease, diabetes and arthritis
- Prescription drugs with a higher risk of abuse and addiction
- Drugs that are mainly recommended for people in certain age groups
- Products where cheaper alternative treatments are available
- Risks associated with the interaction of certain drugs
- Medications not covered by health plans
Why Is Prior Authorization Required?s
Prior authorizations are required by all insurance companies to actively manage costs and to support a value-based health system. The drive towards prior authorization mainly comes down to these factors:
- The need for evidence in support of treatments so that only medically necessary drugs are considered.
- Avoid multiple similar treatments being prescribed in situations where more than one specialist is involved with a patient.
- Reduction in unnecessary costs associated with drugs that don’t fully support the patient’s needs.
- Active monitoring of overprescribing drugs, especially when it comes to pain medication and opioids.
The difficulty for medical professionals is that the list of prior authorization drugs is constantly changing, making it increasingly difficult to fully cover the processes.
Let’s take a closer look.
What Is The Impact On Doctors And Patients?
Unfortunately, there are significant downsides that come with prior authorizations that impact both medical clinics and patients.
Negative Impact On Medical Professionals
Not only does every medical clinic require an admin team that has a full understanding of what drugs require prior authorization, but they also have to know the unique list that each insurance company works with.
And once you have a list of drugs, then you have to understand the different systems used by insurance companies to submit a prior authorization.
The other problem comes from the fact that many doctors see patients outside of normal daytime working hours. And if such doctors don’t have a support team working 24/7, then the request for prior authorization can be further held up.
All of this adds a huge overhead for doctors and admin support teams driving up costs and reducing the amount of time that can be allocated to patient care.
How Can You Streamline The Prior Authorization Process?
The majority of medical clinics and practitioners are not in a position to have a 24/7 admin support team deal with prior authorization requests to speed up the process. There is also the challenge of constantly adapting to health insurance company process changes.
The best way you can reduce your administrative overhead and make your overall admin support team a lot more productive and efficient is by partnering with a prior authorization service provider.
Here at DataMatrix Medical, we have a large team of highly experienced and trained staff that can handle all of your prior authorization needs. Because of the volume of requests we process and our experience with all types of health plans, we have been able to streamline our processes and avoid mistakes that inevitably lead to delays.
What you gain is access to a team that can handle prior authorization submissions 24/7 at a fraction of the cost versus what it would be to handle this in-house.
And you won’t have to worry about a peak in requests that would add strain to your ability to see patients, as we always have more staff than required for extremely busy processing times.
Get Help With Your Pre-Authorization Processes
If you have been struggling with the prior authorization process for prescription drugs and other treatments, then you understand what it ultimately means for patient care and your business.
These admin overheads are not going to get smaller, and you can end up in a spiraling situation where you simply can’t keep up with all the different health insurance company demands.
Call our team today to find out exactly how we can fully integrate with your administrative business processes to speed up the prior authorization turnaround times.
This can be one business decision that transforms your practice.
Nathaniel Smathers, is contributor to the DataMatrix Medical blog with a background in healthcare content creation for over a decade. Nathaniel has a passion for exploring the intersections of healthcare, data analysis, and digital innovation.