Prior Authorization: What You Need to Know

Doing prior authorizations and appealing them was my job in a dental practice. None of the people I ever spoke with at the insurance companies had any dental/medical training. Appeals were a mess and often I had to try 3 or 4 times to get approval.

CRAIN'S COMMENTS

Step Therapy and Prior Authorization are two procedures that health insurance companies have been allowed to introduce to try to limit their exposure to medical claims. Some insurers are increasing requirements for prior authorization, and that could be a major issue for you as a patient.

Prior authorization requires the patient or doctor to apply to the insurer for prior approval before undertaking a specific medical procedure or use of a specific medication. The application goes to the insurer and is reviewed by someone to see if the request is medically appropriate and insistent with the insurer’s guidelines for care.

The person doing the review for the insurer may or may not be a medical professional. The reviewer has no intimate knowledge of the patient or the condition being treated but is expected to second guess the doctor’s recommended course of treatment.

How could that possible go wrong?

  1. Denials to…

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