What is a Prior Authorization?

Have you experienced this statement “I’m sorry, but this requires a prior authorization.”  This very common phrase has become a major complication in the medical community and it is now becoming a heavy burden on the shoulders of patients.

According to insurance companies, Prior Authorizations, also known as P.A.’s, are an extra precautionary step in your overall medical care.  The insurance companies may attach the P.A. requirement to any medical procedure or medication.  Then, they will require the ordering physician to either produce a medical record or conduct a peer –to-peer conversation to justify the medical need.  Examples of such prior authorizations would include:  name- brand medications, MRI scans, and “elective” surgery. 

What does this extra step mean to the patient?  A prior authorization essentially puts a hold on the medication or procedure until the physician meets the necessary requirements set by the insurance company.   The patient will not receive the medication, or be permitted to have the medical procedure, until the P.A. has been satisfied.  Therefore, there is a disruption to your medical care.

What should you do if your medicine or medical procedure requires a P.A.? 

1.   Contact your physician.  Do not assume that your pharmacy or medical facility (such as a diagnostic imaging center), has contacted them.  Make sure they are aware of the issue in detail.

2.   Ask questions.  There are instances that will require the physician to rely on the patients’ past medical history to prove the need for the medication or procedure.  Ask your physician if there is any information you can provide to help speed the P.A. along.

3.   Follow up.  Things fall through the cracks from time to time.  After five to seven business days, call and follow up on the status of the P.A. 

4.   Be patient.  P.A. request are used heavily by insurance companies and your physician’s office has to address each and every request.  It is estimated that each request takes an office staff member approximately 15-25 minutes to complete.

The Arthritis and Infusion Center prides ourselves in “fighting” for the rights of our patients.  We will take the time to complete Prior Authorization requests and prove the need for the medication or procedure.  This personal attention to the needs of our patients is what makes the team at The Arthritis and Infusion Center stand above the rest.