The Prior Authorization Process in a Nutshell

Professional prior authorization services with their experience and expertise boost the prior authorization process to a large extent.

It’s a known fact that prior authorization is an integral part of the medical and healthcare industry. However, even many of the industry insiders are not very aware of how Prior Authorization (PA) really works. To put in a simple way - Prior authorization is a requirement for some treatments, procedures, and/or medicines that a physician obtains pre-approval from the patient’s health insurance plan.  Prior auth is a technique, which reduces cost, time, and effort of all the involved parties including the physician, patient, and the insurance company. However, professional prior authorization services also play a very important role nowadays in the majority of the PA cases taking place. 

Before measuring the extent of the importance the prior auth services play in the process, let’s understand the step-by-step process of a prior authorization.

Step 1: Initiating the Request

The process starts with a prior authorization request being raised by the physician/provider to the patient's insurer. This is to determine whether a prior authorization for the prescribed medicine or procedure is required. The insurance company has to be fed by the requestor (provider) with all the necessary clinical documentation that supports the requisites to obtain an initial authorization. This process might be done manually, sent through fax, or online. The online option is fast becoming the default choice due to its efficiency and since it has less chance of committing errors.

Step 2: Sending the Required Documents

This step constitutes the most important part of this prior authorization process.  Through this step, clinicians ensure to complete their documentation with accuracy and efficiency. After initial documentation is completed by the clinician, it’s time for the authorizations department to send the clinical information along with the designated prior authorization request form to the insurance company (via fax, online, etc.) to obtain authorization for all the future planned visits.

Step 3: The Follow-up

A robust follow-up process is a key to this step. The PA executive does regular follow-ups with the insurance company if they haven’t replied within the usual response period.

Step 4: Reporting the Pending Cases

Last but not the least and it is literally true. This involves report listing of all requested open, pending, or denied cases that are sent periodically. 

Prior authorization is quite a specialized area. The people responsible for the PAs need to self-update themselves continuously. It requires a lot of attention and knowledge of documentation, which the providers’ in-house staffs are unable to provide most of the time. So, to tackle this situation, providers are opening their doors for professional prior authorization services. Professional prior authorization services reduce the online prior authorization woes and also facilitate reduction in other billing errors in the long run. Especially when the industry is unsettled with the ACA subsidy withdrawal and prior auths taking a hit, the professional PA services aiding with fast and efficient online prior authorization tactics is coming as huge reliefs for the medical providers and healthcare centers.

Author's Note

The author of this article writes various blogs and articles on prior authorization (an integral part of medical and healthcare industries), prior authorization process, prior auth online etc.