How to Navigate Prior Authorization.

The ins and outs of getting what you need from your health insurance

By: Deb Gordon, HealthyWomen

One reason for Americans’ low trust in health insurance companies may be one of the industry’s most frustrating practices: prior authorization requirements.

Prior authorization (PA) — also called preapproval, prior approval, preauthorization or precertification — is the process health plans use to decide whether to cover certain services. Many insurers require PA for elective surgeries, non-emergency hospitalizations, certain medications, imaging such as MRI or CT scans, or visits with certain specialists (particularly out-of-network specialists or facilities).

PA rules are based on clinical guidelines and often require patients to try less intensive — and less expensive — treatments before the insurer will approve more expensive approaches.

For example, people with endometriosis may first be required to try nonsteroidal anti-inflammatory drugs (NSAIDs) followed by first-line treatments, such as generic drugs, before they’ll approve second- or third-line treatments — usually newer, brand-name, more expensive drugs.

Surgery might only be covered after medication fails.

If the insurer denies the PA, patients can appeal. If the denial stands, patients are forced to pay out of pocket or go without that care.

Why is prior authorization required?

The obvious motivation for requiring preapproval is to save insurers money. The fewer services they pay for, the more money they make.

But health insurance experts argue there’s more to PAs than just money.

In the best case, PAs ensure patient care follows best practices and protect patients from potential harm from unnecessary treatment, according to Linda Bellgraph, vice president of education at the Endometriosis Association and a retired health insurance professional with more than four decades of industry experience. For example, to treat endometriosis, surgeons may recommend a hysterectomy, which may not always be appropriate or cost-effective.

Farzana Rahman, R.Ph., an executive at Banjo Health, agreed that PAs are meant to ensure appropriate medication use based on expert guidelines, rather than starting patients on the newest (most expensive) drugs. Just because a drug is new doesn’t mean that it’s best for everybody with that disease, according to Rahman.

Often, though, PAs create delays or barriers to care. For example, certain birth control options, medications for skin infections, cancer treatments, arthritis medications or treatment for pain associated with endometriosis may require prior authorization — making the drugs harder to access, which means it takes longer for women to get the care they need.

How to get prior authorization

Bellgraph recommends people should read their member materials. A lot of people get them and toss them without even taking a look, but member handbooks spell out your benefits, rights and responsibilities, including specific coverage rules and PA requirements. Those details can help you follow the rules and avoid surprises. You can always call customer service for your health plan as well.

PA rules depend on the type of insurance you have and where you live. For example, federal rules govern PAs for people with Medicare and Medicaid, though each state administers its own Medicaid program.

Within the regulations, insurance companies set their own processes for what services require PA and what criteria they use to decide on those requests.

Your primary care provider (PCP), or the prescribing or treating provider, typically requests the PA. Providers can only get reimbursed for these services if they get preapproval, so they have a stake in the process, too.

Not everyone has — or thinks they have — a PCP, but most HMOs require members to have one. Even if you don’t realize it, if you have an HMO, you’ve probably been assigned a PCP. Call your health plan to find out who it is so you can get their help with authorization requests.

Depending on your insurance plan and your provider, you may never need to get involved with the prior authorization process. If the request is denied, though, you’ll know. The insurer should notify you of its decision and your right to appeal it by making a request that the company change its decision.

How to appeal a denial

Depending on the type of insurance, you may be entitled to several levels of appeal, each with specific rules and time frames. Even if your request is approved, you may appeal the duration of the approval. For example, if you’re having a one-year course of treatment, you can appeal an authorization that only allows for six months.

“It’s complicated but it’s doable if you can stick with it and keep complaining,” said Lisa Kantor, a California-based healthcare attorney who works with patients whose health insurance companies have denied their claims.

To appeal any part of an insurer’s decision, you may need to send a letter and ask your healthcare provider to do the same, explaining why the service is medically necessary. You can ask for the insurer’s clinical criteria and for a clear explanation of why they denied your request. If the request doesn’t match their criteria, your doctor will probably need to explain why.

Medicare, Medicaid and the Affordable Care Act allow people to start by filing an internal appeal with their health plan and then to request an external review from a state or federal government agency if they don’t get the result they want internally. Each state has an external review process that meets federal consumer protection standards. State departments of insurance or insurance commissioners, consumer protection agencies or attorneys general may also be able to help, depending on the state.

If following the normal timeline would put your health in jeopardy, you can request an expedited appeal from your health plan to speed up the process. 

If you get your insurance through a large employer, they may be exempt from certain rules, which could limit your appeal rights. But, you can also tap into human resources for help. If your employer policy is keeping you from services you need, Kantor suggests contacting the Department of Labor.

According to Kantor, sometimes the process, unfortunately, “requires the person to just dig in and try to figure it out on their own.”

Health plans are judged by accrediting bodies, in part, on how satisfied their members are. When you get a customer satisfaction survey from your health plan, fill it out. Your honest assessment may not overturn a denial, but it can put the insurer on notice that they need to do better for members in the future.

Prior authorization materials prepared by HealthyWomen with the assistance of the Endometriosis Association. AbbVie gave HealthyWomen a grant in support of this project.


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Prior Authorization Doesn’t Have to Be a Barrier to Care

If at first you are denied, try, try again

By: Deb Gordon, HealthyWomen

Even after menopause, Gail Weiss had severe endometriosis that caused her excruciating pain. Weiss researched her options and found a surgeon out-of-state who performed specialized excision surgery. Her insurance company would only pay for a more standard surgery performed by an in-network doctor. The company claimed her local doctor could perform a comparable procedure. Weiss disagreed and got the more specialized surgery without insurance approval. 

After the surgery was done, Weiss’ local doctor reviewed 20 pages of operative notes and confirmed that he could never have performed the same surgery. She used her doctor’s assessment to justify her appeal to the insurance company. Still, they didn’t budge. In all, insurance paid approximately $1,300 — what they would have reimbursed if her own doctor had performed a more basic procedure. 

Weiss wound up paying $3,500 up front for the $15,000 surgery. It took her five years to pay off the rest. 

But, she got her money’s worth. 

Now 12 years later, at age 65, Weiss lives pain-free. 

Red tape

Weiss, who now volunteers with the Endometriosis Association, bumped into a common insurance practice: prior authorization (PA). To get a PA, patients must usually try first-line approaches — such as generic drugs or physical therapy — before insurers will pay for brand-name medication or surgery. 

Though PAs are meant to ensure patients get care consistent with clinical guidelines, in reality PAs often create roadblocks. For example, in response to the opioid epidemic, people with chronic pain often can’t get the medication they need. And people with hard-to-diagnose conditions face dead ends without clear treatment guidelines or objective PA criteria.

“Prior authorization delays access or creates a barrier to receiving care or medications … especially newer therapies,” said Beth Battaglino, RN-C, CEO of HealthyWomen. “The HCP prescribes what the patient needs and then gets hit with a hurdle that takes more time for them to figure out how they can get the right treatment to the patient. When we think about patients who are living with their conditions having to wait another 2 weeks to a month to navigate this barrier, we can see that this is not acceptable. We need change to happen — to allow HCPs to make the decisions on treatment, not the insurance companies.”

According to a 2017 survey conducted by the American Medical Association, 92% of physicians reported that prior authorizations cause delays in patient care. The same percentage reported that prior authorizations negatively impact patients’ health outcomes. Most respondents (86%) reported that prior authorization requirements had increased burdens on their practices over the past five years. 

Patients can appeal denials, sometimes through several levels of escalation. But appeals don’t always succeed and the process itself can cause harm.

“[When] the request is denied, often deemed to be not medically necessary or experimental or investigational, it becomes another hurdle for the healthcare provider and causes delays in  the patient receiving the care they need,” Battaglino said. 

Along the way, patients can find themselves fighting for their lives. 

Not giving up

Julie Eberhardt is certain that fighting prior authorization denials saved her life, but not until after setting her back. 

At the age of 28, following sudden-onset vision changes and numbness, she was hospitalized and diagnosed with multiple sclerosis (MS). 

Eberhardt then had to grapple with her diagnosis and insurance bureaucracy simultaneously. 

Because Eberhardt’s disease was so severe, her doctor prescribed a drug that most MS patients don’t start with. Insurers often require patients to try and fail on lower-cost medications before they’ll approve coverage for more expensive drugs, a process often called step therapy. Her doctor fought the insurer, adamant that the first-line drug wouldn’t work, and Eberhardt wrote a personal statement to humanize the appeal. 

The appeal worked but took eight weeks, during which Eberhardt got worse. “I am 110% convinced … that insurance process caused [me to] relapse,” she said. She wound up in the hospital and in yet another battle with her insurer.

“The insurance companies’ game is just to make it so annoying that you pay [your bill] because you don’t want to deal with it,” Eberhardt said. She had no choice but to fight a $45,000 bill for her first hospitalization. Even with insurance, she couldn’t afford to pay.

Eberhardt enlisted a family friend to help deal with the insurance company. Ironically, as a lawyer, Eberhardt had represented clients against insurers, but her own battle was too personal. The run-around felt like the company was telling her she wasn’t important and they didn’t care that she was sick. That’s the last thing a sick person wants to hear. They want to know that someone’s trying to help,” she explained.

When Eberhardt later discovered she was eligible for an expensive stem-cell transplant, she decided to approach the insurer in a language she felt they would understand: dollars and cents. She didn’t bother trying to emphasize her humanity. 

On a $12,000-per-month medication, which insurance covered after Eberhardt paid approximately $5,000 to meet her deductible and out-of-pocket maximum, she might cost her insurance company millions of dollars over time. She argued they’d save money if the $175,000 transplant worked. 

Her appeal worked. And so did the transplant. Now approaching the three-year anniversary of the procedure, her symptoms are nearly undetectable. Eberhardt estimates that her insurance company saved $492,000, more than double what they paid for her transplant. 

When it comes to fighting prior authorization denials, determination pays off. “The key is to educate yourself about your health plan’s prior authorization rules, make sure you know your rights and perhaps enlist someone to help you navigate the process. And be persistent,” Battaglino said. 

Being persistent did the trick for Eberhardt. She refused to give up. When her neurologist had told her early on that she would likely be wheelchair-bound by age 35, she took it as a challenge to find alternative treatments. She has avoided that fate largely because she persisted — and prevailed — in her fight for insurance coverage.

Prior authorization materials prepared by HealthyWomen with the assistance of the Endometriosis Association. AbbVie gave HealthyWomen a grant in support of this project.