Recently, a report from the HHS Office of Inspector General (OIG) and a corresponding article in the New York Times have raised concerns regarding the utilization of prior authorization in Medicare Advantage.
“With over 28.5 million Medicare Advantage beneficiaries today, it’s worth noting that the OIG report questioned 33 prior auth denial cases in a single week in June 2019.”
This represents a very small fraction of Medicare Advantage beneficiaries, making it somewhat challenging to draw sweeping conclusions about Medicare Advantage practices based on such a limited sample.
The reporting in the Times did not take into account data provided to the reporter by Better Medicare Alliance before the article’s publication. Instead, it opted for a sensational headline that cautioned, “Medicare Advantage plans often deny needed care, federal report finds.” While Better Medicare Alliance has consistently advocated for efforts to streamline and simplify the prior auth process, it is essential that policymakers, beneficiaries, and readers of the Times receive a clearer understanding of the role of prior authorization in Medicare Advantage, how extensively it is employed, and its impact on consumers.
When it comes to navigating the complex world of healthcare, one term that often arises is “prior authorization” or “prior auth.” Although it may sound like an intricate process, fear not! In this comprehensive blog, we’ll delve into the depths of prior auth, shedding light on what it entails and providing a detailed answer to the pressing question: how long does a prior auth take?
What is Prior Authorization (Prior Auth)
Prior authorization, often referred to as “prior auth,” is a process that healthcare providers must go through to get approval from insurance companies before certain medical procedures, treatments, or prescription medications can be provided to patients. It’s like getting a permission slip from the insurance company before proceeding with specific healthcare services. It is a crucial process employed by health insurance companies to determine whether they will cover specific medical treatments, procedures, or medications. Think of it as obtaining permission before proceeding with a treatment or medication prescribed by a doctor.
The Purpose of Prior Authorization
You might wonder why insurance companies use prior auth. The primary objectives are cost control and ensuring that the recommended treatments or medications are medically necessary. This approach prevents unnecessary spending on treatments that might prove ineffective or could be substituted with more cost-effective alternatives.
Prior Authorization Use in Medicare Advantage
Medicare Advantage plans, also known as Medicare Part C, often require prior auth for various healthcare services. This includes hospital stays, surgeries, certain medications, and medical equipment. Medicare Advantage plans aim to ensure that the provided services are medically necessary and cost-effective.
Measuring the Impact of Prior Authorization
Prior authorization can have both positive and negative impacts. On the positive side, it helps control healthcare costs, prevents fraud and abuse, and ensures that patients receive evidence-based care. However, it can also lead to delays in patient care and administrative burdens for healthcare providers.
Based on information from CMS, the latest scores in Medicare Advantage indicate that around 90 percent of individuals currently enrolled in Medicare Advantage plans offering prescription drug coverage are in plans that have received four or more stars out of five. CMS also notes that in comparison to the previous year, there are more plans with ratings of 4 or more stars in 2022. This increase reflects improvements in health plans’ performance across various measures.
A closer examination of the data reveals that Medicare Advantage plans have notably enhanced their performance in areas such as “reviewing appeals decisions,” “providing timely appointments and care,” and “evaluating healthcare quality” when comparing year-over-year data.
Clearly, this broader dataset offers a more comprehensive perspective than the OIG’s limited sample of 33 disputed prior auth denials, which accounts for just 0.0001% of Medicare Advantage beneficiaries. This data contradicts the Times’ claims that beneficiaries are consistently being denied essential care that should be covered under the program.
A Step-by-Step Look at the Prior Authorization Process
Let’s break down the prior authorization process into its essential steps:
- Doctor’s Recommendation: It all begins with healthcare provider recommending a specific treatment, procedure, or medication. They will compile and submit all the necessary information regarding a patient’s condition and why they believe this particular intervention is crucial for one’s well-being.
- Insurance Submission: The next step involves the healthcare provider’s office submitting a formal request to the insurance company. This request comprises all the required medical information, including a patient’s diagnosis, the recommended treatment, and the medical necessity of the procedure.
- Review Process: Upon receiving prior auth request, the insurance company initiates a comprehensive review. They assess whether the request aligns with their criteria for coverage. If additional information is needed to make an informed decision, the insurance company may contact healthcare provider for clarification.
- Decision Time: This is the stage where the burning question arises: how long does a prior auth take? The duration of the prior authorization process can vary significantly. It hinges on factors such as insurance company’s policies, the complexity of the medical case, and the urgency of the treatment. The timeline can range from a relatively swift few days to a more protracted wait spanning several weeks.
- Approval or Denial: After completing their review, the insurance company will communicate the outcome of prior auth request. The patient will receive a notice specifying whether their request has been approved or denied. If approved, they can proceed with the recommended treatment with the assurance that insurance will cover the costs. If denied, they may have the option to appeal the decision or explore alternative treatment options with the healthcare provider.
Strategies to Expedite the Prior Authorization Process
While a patient may not have direct control over the insurance company’s timeline, there are proactive steps they can take to facilitate a smoother process:
Follow Up: Maintain regular communication with both healthcare provider’s office and the insurance company to ensure they have all the necessary information and documents.
Be Informed: A crucial aspect of expediting the process is understanding insurance policy thoroughly. Familiarize a patient with what their policy covers and the specific requirements for prior auth. Being well-informed empowers a patient and their healthcare provider to submit a comprehensive and accurate request.
Patience Is Key: Understand that the duration of the prior authorization process can be influenced by various factors. It’s essential to remain patient while awaiting a decision. If a patient’s request is denied, remember that they often have the opportunity to appeal the decision or explore alternative treatment options in consultation with healthcare provider.
In conclusion, prior auth represents a necessary and prudent step within the realm of healthcare and insurance. While it may entail some waiting, the underlying goal is to ensure that the patient receives the right treatment at a reasonable cost. So, the next time you find yourself pondering, “how long does a prior auth take?” remember that the timeline can vary but staying informed and patient will help navigate the process with confidence.