Prior #Authorization

• Preauthorization is A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment (DME) is medically necessary.  Sometimes called prior authorization, prior approval or  precertification.
• Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost. ^{Health Net Glossary}  * See also YOUR EOC, Evidence of Coverage!
• IMHO Insurance Companies are not doctors and a lot of people and regulators agree, thus the pending laws and investigations.
  • Exhausted by prior authorization, many patients abandon care: AMA survey
    • hawaii news now.com/ doctors-say-insurance-approval-reform-would-help-patients-get-care-faster/
    • kff health news.org/prior-authorization-outrage
  • Prior Authorization in Medicare Advantage Plans: How Often Is It Used?  KFF 10/2018
  • Prior Authorization - Regulatory Investigation aka “preauthorization” and “precertification” KFF.org 5.20.2022
  • California Senate Bill 250  * Senator Pan   would require that insurers consult with doctors on which services require authorizations, streamline the process, less paperwork and allow patients to get the care they need faster.
    • SB 250 would require health plans to exempt physicians from prior authorization rules if they have practiced within the plan's criteria 80% of the time. ^CMA.Docs.org
  • PRIOR AUTHORIZATION REQUIREMENTS HALTED FOR CERTAIN SERVICES 
  • Parody If Health Care was honest  VIDEO
  • UnitedHealth launches ‘gold card' to ease prior authorization burden
  • Use of Prior Authorization Up in Medicare Advantage Plans, Senate Report Finds
  • ajmc.com/prior-authorizations-and-the-adverse-impact-on-continuity-of-care
• See our main webpage on Medical Necessity
• Appeal & Grievances?
  • Medical Necessity – reasonable and necessary Independent Medical Review
    • IMR Independent Medical Review
    • Knee and Hip Replacement Medical Necessity
    • Prior Authorization
    • Varicose Veins Cost Medical Necessity
  • Understand Insurance Policies EOC Evidence of Coverage
    • Fraud, Scams, Waste & Abuse Risk Adjustment
•  

Resources, Links & Bibliography

• cal matters.org/new-bill-pushes-insurers-to-stop-playing-doctor
• Payer Denial Tactics — How to Confront a $20 Billion Problem
• cal matters.org/richard-pan
• cma docs.org/prior-authorization-bill
• Plaintiff whose insurer delayed surgery is awarded $14 million over opioid dependency
• SCAN Pharmacy Prior Authorization Forms  SCAN Website
  • General Prior Authorization  SCAN Website
• Her spine surgery was denied. Doctors say it's all too common.
  Insurance denied 18-year-old Nala White’s surgery for degenerative disc disease. After NBC News reached out, it was approved the next day.    NBC News.com