Advocating for Your Rights to Prior Authorization: A Patient's Guide

Advocating for Your Rights to Prior Authorization

In the realm of healthcare, individuals often find themselves entangled in a struggle, where their health outcomes may depend on obtaining approval from a healthcare ‘gatekeeper.’ This gatekeeper commonly manifests as an authorization (PA) mandate in today’s healthcare landscape. This procedure necessitates patients, their doctors, and healthcare providers to navigate through requirements before medications, services, or equipment can be covered by insurance. The prior authorization process is an obstacle to receiving timely and essential care for individuals.

According to a 2018 survey conducted by the American Medical Association, 91% of physicians have noted an escalation in the burden of authorizations over the five years, with 28% indicating a ‘significant’ increase in this burden. This strain inevitably impacts care. In light of these concerns, legislation and guidelines are being introduced to safeguard patients’ rights; however, patients must comprehend their rights and how they can assert them effectively. In this article, we delve into the intricacies of authorization. Provide guidance on navigating through claims and appeals processes.

Understanding Prior Authorization

Insurers use prior authorization to manage expenses and ensure that patients receive treatment that meets their needs.
However, critics often mention that the process can be time-consuming, intricate, and, at times, unnecessary, causing delays in treatment and frustration for both doctors and patients.

The general procedure includes the following steps:

• A healthcare provider suggests a treatment, test, or medication. The provider team sends an authorization request to the patient’s insurance company.
• The insurance company evaluates the request based on evidence-based guidelines. The insurance company might approve, deny, or ask for information (resulting in communication and potential delays).
• Treatment can only begin after receiving approval. Patients also need to participate by advocating for themselves.
• One crucial step is ensuring all interactions with their insurer are well documented and understanding their policy terms regarding authorizations. Patients have rights in the authorization process as outlined by state laws and sometimes by their insurance policies. These rights include:

Right to Information

Patients have the right to receive adequate information about the authorization process, including the criteria used by their insurance company. If their authorization request is turned down, patients can challenge the decision. They can ask the insurer to review the decision and explain why they need the treatment. Waiting for a review could harm a patient’s health, so they can request an expedited review. Patients can ask for their treatment to be overseen by a specialist of their primary care doctor. Patients have the right to continue receiving care during the review of an authorization request. If treatment has already started, the insurer can only stop it after deciding. To ensure that a patient’s rights are upheld in the authorization process, it’s important to take steps. Here are vital actions patients should consider:

• Reviewing and understanding their insurance policy to know what is covered when prior authorization is needed and other important details. Learning about the authorization process, including which treatments require it and how to request it.
  Working closely with your doctor is crucial during the authorization process.

  

• Ensure that the medical staff at your doctor’s office are well trained to handle authorizations and have a system to notify patients when a prior authorization is needed. It’s important to keep records of every conversation, including the time and date of the phone call, the name of the insurance representative you spoke with, and the outcome of the call.
• Stay organized by keeping a record of all test results, medical records, and any other documents supporting the necessity of your treatment.
• Familiarize yourself with your insurance provider’s appeals process. Understand the timelines for appealing a denial and know what steps are required to initiate an appeal.
• Utilize communication channels to contact your insurance company to ensure that information is received and processed effectively. Remember that patience and persistence are essential when dealing with authorizations. Stay proactive, maintain communication with your healthcare team, and know you can appeal any decisions made.