Blue Buzz: How ‘Prior Authorization’ Could Affect the Care You Receive

Have you ever wondered why a health care treatment requires a “prior authorization?” Prior authorizations are a useful tool resulting in better financial and health outcomes for patients. Check out the latest Blue Buzz video to learn more.  

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Let's say you're in the doctor's office for a medical condition. She's able to diagnose your problem and sends you off with a proposed treatment plan. But as you're checking out, they tell you have to wait to receive the care while they contact your insurer for something called "Prior Authorization."   

What? You were just in the room with the doctor. What needs to be authorized? You said OK to the treatment she proposed. To be covered by your insurance plan certain non-emergency services supplies and drugs may have to go through a process called prior authorization your doctor agreed to share information with your insurer to make sure inappropriate care is not needlessly delivered.  

The insurer's discussion with the doctor can go something like this: "Is this really medically necessary? Is this a typical treatment for this condition?" "Yes, it really is legit. Here's why." "Thanks. Just checking."  

It's like that but with a board of reviewers and physicians and specialists all comparing the treatment your doctor proposed against a set of clinical standards and evidence-based guidelines. These standards and guidelines are developed to help recommend the most effective care.  

In some special circumstances including during the COVID-19 pandemic. These processes may be different, and you may not go through a prior authorization before receiving certain health care services. You'd be surprised how much unintentional waste can be prevented through prior authorization and sometimes both physicians and patients just outright abuse the system by committing intentional fraud.  

For example, every year the U.S. spends about three point five trillion dollars on health care about 750 billion of that is lost to fraud waste and abuse.   

Preventing the over prescription of drugs and the overuse of imaging scans and even some surgeries, well that means that you and other members of the health plan are not needlessly exposed to radiation or complications from surgery. It also keeps your insurance premiums as low as possible. Not to mention if a procedure a test or a drug is not necessary then it may not actually help you get better.  

It's just delaying you from getting the care you may really need. Or it could be keeping you from an alternative that may be less risky and more affordable. But beyond the financial aspect the process serves as an extra layer of accountability. It oversees the patient's entire journey far outside just a single doctor's office.  

Think about it like this. An insurer like Blue Cross and Blue Shield of Texas has more than 80000 health care providers all submitting claims to the system. As an insurer, we try to look out for each of their six million members, the entire risk pool. And with all those people involved mistakes are bound to happen. Unfortunately, there are also a few bad actors in the bunch. But by taking a second look at certain treatments the insurance company can weed out mistakes and those bad actors and ultimately help all of the members.   

For example, let's say you see a new doctor. He does a thorough review of your medical history but you totally forgot to mention that you've had an allergic reaction to a certain type of pain medication in the past with the best intentions the doctor prescribes the same medication to treat your back pain.   

Fortunately, during the prior authorization process your health insurer notices your previous allergic reaction. The insurance company alerts your doctor about the allergy and your doctor recommends an alternative medication that won't make you break out in hives. Your provider updates your prescription and you're on your way to feeling better. Or for instance perhaps your physician recommends surgery to treat an injury you suffered while mowing the lawn.  

However, the latest clinical studies and the guidelines show that more patients are recovering from the injury through therapy than surgery. In that case therapy would be covered as a medically necessary treatment plan for the injury. This happens more often than you might think. It's no secret that the health care system is confusing on the patient's journey. There are just so many moving pieces.  

Doctors and specialists, surgeons are all working towards the same patient outcome. Sometimes you really need a bird's eye view of the patient's entire treatment. There is no perfect system, but prior authorization is a useful tool resulting in better financial and health outcomes for patients.  

Help others understand the purposes behind prior authorization. Share this video with a friend or family member living with a complex health care condition. Got questions? Call the number on the back of your I.D. card to get answers.