In Authorizations, Prior Authorization

There are a lot of administrative pain points that providers have to deal with in the medical field, and one of the most common issues is prior authorization. This can be a frustrating hurdle that providers need to clear before they can perform a test or dispense certain medications for their patients, especially if they don’t know that there are other ways how prior authorization works. Since there is so much to know, a medical practice should utilize expert prior authorization services to ensure the claims will be reimbursed. 

What Is Prior Authorization?

Prior authorization is a process insurance companies use to determine if a prescribed product or service (imaging studies, medications, surgeries, etc.) will be covered. The prior authorization ensures that the service will be paid in full or in part. For example, once a provider orders an MRI for a patient, the provider may have to reach out to the insurance company to see if they will cover the cost of the MRI. says healthcare professionals could have saved $13.3 billion on administrative waste in 2020. Prior authorization can be a frustrating hurdle because it can delay the process of patients receiving the care they need. Therefore, doctors need to understand how prior authorization works and how they can maximize the chances of getting the claim covered. A service like DataMatrix can help the practice’s bottom line. 

How Prior Authorization Work?

There are several steps to follow so that prior authorizations work. Here are a number of those steps. 

  • The doctor will usually try to order an Imaging scan or a specific medication. After the order is put through, the person running the task will be alerted to the prior authorization status of that medication or test. For example, if a doctor orders a medication or trial, the practice must check with the insurance company for prior authorization.
  • At this time, the practice needs to start a prior authorization process. The information required to submit the request can vary from insurance to insurance. Typically, this process is handled over the phone, via a secure email server, or through fax.
  • It is not unusual for a prior authorization situation to take a few days or weeks to resolve. It may require multiple phone calls, and it could require a lot of waiting.
  • At the end of the process, the insurance company will either approve or deny the prior authorization request. If the claim is denied, the doctor may have an avenue for appealing the decision.

Doctors need to understand every option because this process can take such a long time.

Professional Services Can Streamline the Process

Even though it can be frustrating to go through the prior authorization process, this is not something that medical practices have to go through on their own. There are professional services available that can make the process easier.

There is no reason why doctors shouldn’t outsource prior authorization services to a specialist to understand the most common reasons why a prior authorization might not be approved. They can anticipate these issues, avoid these obstacles, and make it easier for patients to get the care they need.

This can also take much stress off the shoulders of practice because they do not have to do as much paperwork. Providers can spend their time helping their patients, focusing on making the best possible medical decisions for their needs.

Types of Medical Procedures Requiring Prior Authorization: A Comprehensive Overview

Prior authorization is crucial in healthcare, ensuring that medical procedures and activities are appropriate, safe, and cost-effective for patients. This process involves obtaining approval from insurance companies or healthcare providers before specific treatments, tests, or services can be carried out. While the specifics may vary, here is a comprehensive summary of the types of medical procedures and activities that commonly require prior authorization.

  1. Specialty Medications: Certain medications, especially high-cost specialty drugs, may require prior authorization. These medications often treat complex conditions such as autoimmune diseases, cancer, or rare genetic disorders. The prior authorization ensures that patients meet specific criteria and use these powerful medications appropriately.
  2. Advanced Imaging and Diagnostic Tests: Procedures like MRIs, CT scans, PET scans, and genetic testing may need prior authorization. These tests are valuable tools in diagnosing and monitoring various conditions. Insurance companies often want to confirm that these tests are necessary and will provide helpful information for the patient’s healthcare.
  3. Surgical Procedures: Certain minor and significant surgeries might require prior authorization. This can include elective surgeries, organ transplants, bariatric procedures, and more. Prior authorization helps ensure that the proposed surgery is medically necessary and that the patient meets specific criteria.
  4. Inpatient Hospital Stays: Admission to a hospital for specific conditions or treatments may require prior authorization. Insurance companies want to verify that the hospital stay is medically necessary and that the proposed treatment cannot be effectively administered on an outpatient basis.
  5. Home Healthcare Services: Home healthcare services, such as skilled nursing care or medical equipment delivery, may need prior authorization. This process helps ensure that patients receive the necessary care and equipment in the comfort of their homes.
  6. Physical Therapy and Rehabilitation: Insurance companies might require prior authorization for extended physical therapy or rehabilitation courses. This confirms that the treatment plan is appropriate and aligns with the patient’s medical needs.
  7. Specialty Consultations: Consultations with specialists outside a primary care physician’s network often need prior authorization. This step allows the insurance company to confirm that the referral to the specialist is appropriate and will result in effective medical care.
  8.  Durable Medical Equipment: Medical equipment like wheelchairs, oxygen tanks, and CPAP machines may require prior authorization. This process ensures that patients genuinely need the equipment and that it will contribute to their health and well-being.
  9. Infertility Treatments: Assisted reproductive technologies like in vitro fertilization (IVF) or intrauterine insemination (IUI) may need prior authorization. Insurance companies might want to verify that these treatments are medically necessary and that patients meet specific criteria.
  10.  Non-Emergency Transportation: Transportation services for medical appointments, especially if specialized vehicles are required, might need prior authorization. This helps insurance companies ensure that transportation is necessary due to a patient’s medical condition.

In conclusion, prior authorization is an essential process in healthcare that aims to balance patient needs with cost-effectiveness. It ensures that medical procedures and activities are carried out appropriately and beneficially. While the specifics of what requires prior authorization can vary between insurance plans and healthcare providers, the common thread is the commitment to delivering safe, effective, and necessary patient care. Patients and healthcare providers collaborate in this process to ensure the best possible outcomes for all parties involved.

Trust DataMatrix Medical for Prior Authorization Help

To ensure your patients get the care they need, you must work with professionals who can handle the prior authorization process for you. At DataMatrix Medical, we have a tremendous amount of experience working with various medical practices, and we can help you make it easier to get your prior authorization processed. If you want to learn more about how he can help you, contact us today to speak to a team member.

Recent Posts
Do you need prior authorization for orthopedic visitsoutsourcing prior authorization