Prior authorization

Prior Authorization is a requirement that a healthcare provider must obtain approval from a health insurance plan to prescribe a specific medication, medical procedure, service, or device for the insured patient. This process is intended to act as a safety and cost-saving measure, although it has been criticized for adding complexity to the healthcare system.

Overview

Prior authorization is used by insurance companies to manage costs and ensure that treatments are used appropriately. The process involves a review by a medical director or pharmacist who works for the insurance company. They review the request and the patient's medical records to determine if the treatment is necessary and appropriate.

Process

The process for obtaining prior authorization varies by insurance company and by the type of service or medication being requested. Generally, the healthcare provider must fill out a form that includes information about the patient's medical history, the proposed treatment, and the reason the treatment is necessary. This form is then submitted to the insurance company for review. If the request is approved, the treatment can proceed. If the request is denied, the healthcare provider can appeal the decision.

Criticism

Critics of prior authorization argue that it adds unnecessary complexity to the healthcare system and can delay or deny access to necessary treatments. Some studies have found that the process can take up to several hours per week for healthcare providers, which takes away from patient care. Additionally, some patients may abandon their treatment if the authorization process is too burdensome.

See also

• Health insurance
• Healthcare provider
• Medical director
• Pharmacist