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Impediments for Prior Authorization: How Patient Advocates Can Make a Difference

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Express Scripts prior authorization is a process that requires healthcare providers to obtain approval before certain prescriptions are filled. This ensures that the prescribed medications are necessary and covered under the patient’s insurance plan, helping to manage costs and ensure appropriate use of medications.

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Table of Contents

Impediments for Prior Authorization

impediments for prior authorization focus doctorHealthcare providers and patients often find authorization (PA) an aspect of the healthcare system. This process involves obtaining approval from insurance companies before administering treatments or medications, aiming to manage costs and ensure the use of healthcare resources. However, it frequently results in care delays, which add stress for patients. This article delves into the obstacles of authorization and highlights patient advocates’ crucial role in overcoming these challenges.

Exploring Prior Authorization

What’s Prior Authorization?

Prior authorization is a utilization management tool health insurers use to determine coverage for procedures, services, or medications. Healthcare providers must typically submit documentation and justifications before treatment approval is granted.

The Purpose of Prior Authorization

The objective of PA is cost control, ensuring patients receive suitable care. Insurers argue that it helps prevent treatments and monitors appropriate medical service usage. Nevertheless, it often leads to delayed treatments and increases administrative burdens on healthcare providers.

The Struggles with Prior Authorization

Administrative Challenges

One issue with PA is the administrative workload it imposes on healthcare providers. Doctors and their teams must invest time and effort in completing paperwork, making follow-up calls, and sharing patient information with insurers. This paperwork can detract from the quality time and attention that providers could otherwise dedicate to direct patient care.

Treatment Delays

A problem arising from the PA process is the delays in accessing treatments and medications. When approvals are slow to arrive, patients may endure prolonged suffering. See, their conditions deteriorate. These delays can be incredibly disruptive for individuals living with life-threatening conditions.

Emotional Impact on Patients

For patients, the PA procedure can trigger stress and anxiety. The uncertainty of waiting for approval can take a toll, especially when urgent treatment is needed. Patients may feel powerless and frustrated by a complex system indifferent to their circumstances.

Understanding Patient Advocates

Who Are Patient Advocates?

Patient advocates help patients navigate the healthcare system. They could be healthcare professionals, like nurses, social workers, or trained laypersons dedicated to assisting patients. The responsibility of advocates is to assist individuals through healthcare procedures, ensuring they obtain the necessary treatment.

How Patient Advocates Assist with Prior Authorization

Patient advocates play a role in addressing the complexities associated with the PA process. Here are various ways in which they can have an impact:

Specialized Knowledge in Navigating Insurance Procedures

Patient advocates understand the insurance landscape and the intricacies of the PA process. They are well-versed in the required documentation, standard timelines, and common rejection reasons. Leveraging this expertise, they can promptly submit all information, decreasing the chances of delays or refusals.

Efficient Communication

Advocates act as liaisons between patients, medical professionals, and insurance companies. They can effectively convey the urgency and significance of treatment by convincingly advocating on behalf of the patient to insurers. Their ability to articulate the necessity can play a role in obtaining timely approvals.

Emotional Assistance

Patient advocates offer support to individuals who may feel overwhelmed by the PA process. They provide comfort, address inquiries, and offer updates to help patients feel more informed and empowered. This assistance can significantly alleviate the worry and stress of waiting for approval.

Support for Appeals

In cases where a prior authorization (PA) request is turned down, advocates can step in to help with the appeals process. They are familiar with the procedures involved in appeals and can aid in gathering documents, drafting appeal letters, and advocating for the patient’s best interests. Their support plays a role in overturning rejections and ensuring patients get the necessary care.

Real-life Example: A Case Study

Let’s examine an example to demonstrate how patient advocates make a difference. Take “Sarah,” a patient dealing with an autoimmune condition. When Sarah’s doctor prescribed a biologic medication to effectively manage her symptoms, she faced a denial due to insurance requiring prior authorization. At this juncture, a hospital patient advocate intervened. Working closely with Sarah’s doctor, the advocate compiled records detailing Sarah’s condition and presented clinical reasons for using the biological medication. The advocate also maintained communication with the insurance provider, stressing the urgency of Sarah’s situation.

After weeks and a successful appeal process, approval was granted for the medication. Though there was some delay in starting treatment, thanks to the advocate’s skills and determination, Sarah eventually received the medication. This situation highlights patient supporters’ role in overcoming obstacles related to authorizations.

Strategies for Successful Advocacy

impediments for prior authorization smiling nurse

Establishing Strong Relationships with Insurers

One advocacy approach is to build cooperative relationships with insurance companies. By fostering communication and understanding the insurer’s policies and criteria, advocates can work efficiently to speed up the prior authorization process and address issues promptly.

Keeping Abreast of Policy Changes

The landscape of healthcare insurance is continually changing, with insurers revising their authorization requirements and policies. Patient advocates must stay informed about these changes to navigate the system effectively. Attending training sessions, participating in industry conferences, and subscribing to newsletters can assist advocates in staying up to date.

Utilizing Technological Resources

Technology can serve as a tool for advocates. For instance, electronic health records (EHR) systems can streamline the collection and submission of documentation. Moreover, specialized software platforms can simplify the authorization process by enabling advocates to monitor submissions and track status updates. Ensure timely follow-ups.

Collaborating with Healthcare Professionals

Advocacy often entails collaboration with healthcare providers. By collaborating with physicians, nurses, and administrative personnel, patient advocates can ensure that all essential clinical information is effectively gathered and presented. Adopting a team-based approach can be beneficial for patients to improve their chances of an outcome.

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Board Certified Family Medicine Physician

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Mohammad Ashori, M.D.

Board Certified Family Medicine Physician

100 satisfaction

Looking Ahead: Prior Authorization and Supporting Patients

impediments for prior authorization old woman patientProposed Changes in Prior Authorization

There is a growing understanding of the necessity to revamp the authorization (PA) process to lessen its impact on patients and healthcare providers. Some suggested changes include standardizing PA requirements across insurance companies, introducing time-based electronic PA systems, and reducing the need for prior authorization for specific medications and treatments. If these modifications are implemented, they could significantly reduce the workload and emotional strain experienced by patients and providers.

The Increasing Significance of Patient Advocacy

Advocates’ roles are expected to become more crucial in the future. With transformations in the healthcare sector, there will be a heightened demand for individuals with knowledge and empathy to navigate its complexities. Investing in training programs and resources for advocates will be vital to ensure they can effectively support patients.

Final Thoughts

Prior authorization presents hurdles for patients and healthcare providers, often leading to treatment delays, administrative challenges, and emotional pressure. Nonetheless, patient advocates play a role in overcoming these obstacles. Through their expertise, communication skills, emotional backing, and advocacy efforts, they can make an impact on guiding patients through the PA process and ensuring they receive necessary care. The significance of advocacy will continue to increase as the healthcare environment changes, emphasizing the necessity of backing and nurturing these positions.

To learn more about benefit management that can enhance your medical practice. Discover more about Portiva and unlock a world of possibilities by visiting our homepage today!

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