Understanding Prior Authorization
The United States has one of the most expensive health systems in the world, and waste is one of the driving forces.
What is considered waste in healthcare?
- Excess costs that could be avoided by replacing services or products with cheaper alternatives that have the same or better benefits.
- Money spent on things that don’t help patients get better or stay healthy such as unnecessary tests and overtreatment.
About 30% of healthcare spending is estimated to be considered waste. One of the ways health insurance companies can reduce wasteful spending is through prior authorization.
What is a prior authorization?
Prior authorization, sometimes called pre-authorization, is a process where healthcare providers must get approval from health insurance companies before certain medications, procedures, or services can be covered. Prior authorization requests can be approved or denied.
What is the prior authorization process?
A team of nurses and doctors on the health insurance side will review your medical condition and overall case and confirm that the medication, service, or procedure the provider requested:
- Is the best option for the patient's unique health needs
- Is medically necessary
- Meets the current standard of care
- Follows policies
How can prior authorizations save you money?
The healthcare professionals reviewing prior authorizations determine if there are, for example, less risky or less-invasive options that haven’t been considered yet that would lead to the same or better health outcomes. Less invasive options are generally less expensive. The healthcare teams that review prior authorizations can help confirm your care is appropriate and necessary, so you don’t get billed for something you didn’t need, won’t benefit you, and could even be harmful.
Examples:
- If a patient’s symptoms can be effectively managed with treatment like physical therapy or medication, prior authorization may discourage a costly major surgery. This helps avoid invasive procedures with greater risk of complications and unnecessary expenses for services that may not improve the patient’s health and well-being.
- Prior authorizations may require healthcare providers to consider lower-cost alternatives, such as generic medications, before prescribing brand-name drugs. This helps control healthcare spending without compromising the quality of care, as generic medications are typically just as safe and effective as their brand-name counterparts but are available at a lower cost.
“I love reviewing prior authorizations because it gives us a chance at AZ Blue to really advocate for an effective and appropriate treatment plan, ensuring our members get the right kind of treatment and they don’t get a test or procedure without first considering options that may be less invasive and more beneficial to their health.” - AZ Blue nurse
How long does the prior authorization process take?
The time it takes to complete a prior authorization can vary depending on several factors including the health plan you have and the complexity of the request. Some prior authorizations can be processed quickly, especially for urgent healthcare needs.
Blue Cross Blue Shield of Arizona (AZ Blue) has implemented teams and launched programs that make it easier to get the care you need when you need it.
- Clinical Rapid Response Team: If you have a health scare, like a life-altering diagnosis, AZ Blue’s Clinical Rapid Response team can move fast on prior authorizations – so you can get the procedure, treatments, and/or medication you need without delay. AZ Blue members can contact the team directly if they need help: Clinical Rapid Response | AZ Blue
- Gold Card Program: This AZ Blue program offers automatic prior authorization approvals to qualifying providers, so certain medical services can be processed and approved within minutes! Please note this program is not available to all providers or for all healthcare services. For more information, visit: Prior Auth & Medical Policies | Gold Card Program | AZBlue