Prior authorization isn’t limited to one particular type of healthcare service. Your practice may need to get approval before prescribing a medication, performing a procedure, ordering medical equipment, or providing certain treatments.
Given how broad the scope of prior authorization is, it can easily take a considerable amount of time from your practice staff. As a matter of fact, the American Medical Association shows that healthcare practices complete an average of 40 prior authorizations per physician every week. That means your team may be working on multiple kinds of requests at any given time, which can be very demanding for practices with smaller teams.
To effectively manage prior authorization, it helps to know the different types of prior authorizations your practice may encounter so you can easily determine what needs to happen next.
1. Prescription Drug Prior Authorization
Some prescription medications need approval from a patient’s health plan before they can be covered. This is especially common when there are specific requirements the patient needs to meet before their plan will cover the prescribed medication.
For example, the insurer may ask whether the patient has tried another medication first or require clinical information that supports why the prescribed drug is appropriate.
This is why checking the patient’s formulary and coverage requirements matters. Even if you’ve prescribed the same medication to other patients, it doesn’t necessarily mean their health plans will have the same requirements.
2. Medical Procedure Prior Authorization
Certain medical procedures and surgeries may also require approval.
In this case, the health plan may ask for medical records and other clinical information showing why the procedure is necessary. This could include the patient’s diagnosis, previous treatments, test results, or notes from their provider.
Ideally, your team should verify these requirements while the procedure is still being planned. Otherwise, finding out that an authorization is missing later on can delay when the patient receives care.
3. Diagnostic Imaging Prior Authorization
MRIs, CT scans, PET scans, and other advanced imaging services may require prior authorization. Before scheduling one, your staff may need to provide the patient’s diagnosis, symptoms, previous tests, and other information that supports why the imaging is necessary.
This is particularly important to verify beforehand. Your patient could already have an imaging appointment scheduled before your practice finds out that their health plan requires approval.
4. Durable Medical Equipment Prior Authorization
Prior authorization doesn’t only apply to treatments and procedures. Certain durable medical equipment (DME), such as wheelchairs and CPAP machines, may also require approval.
For example, Medicare requires prior authorization for certain items on its DMEPOS Prior Authorization List. When an item requires it, the necessary documentation needs to be submitted for review before the equipment is provided.
Depending on how the equipment is ordered, your practice may also need to coordinate with the supplier to make sure the required information is available.
5. Specialty Care Prior Authorization
Specialty care can come with its own authorization requirements. Depending on the patient’s health plan, these can apply to certain specialist services, behavioral health care, home health care, skilled nursing, and inpatient services.
One thing to watch out for here is the difference between a referral and prior authorization. A referral typically comes from a healthcare provider and directs the patient to another provider or specialist. Prior authorization, on the other hand, involves getting approval from the patient’s health plan.
In some cases, your patient may need one or both before receiving specialty care.
6. Treatment and Therapy Prior Authorization
Physical therapy, occupational therapy, speech therapy, infusion therapy, and other treatments may also require prior authorization.
Unlike a one-time procedure, however, these services may involve multiple visits. An authorization could therefore come with a limit on the number of sessions or specify how long the approval remains valid.
For example, if a patient is approved for a certain number of physical therapy visits but needs additional sessions, your team may need to request another authorization. Keeping track of these limits can help you avoid finding out that an authorization has expired while the patient is still receiving treatment.
Get More Support With Prior Authorization
Keeping up with different prior authorization requirements can take time, especially when your team is managing requests for multiple patients and health plans.
As a solution, My Mountain Mover can help you find HIPAA-compliant, healthcare-trained virtual assistants to whom you can delegate prior authorization tasks. Schedule a free discovery call today to learn more.
Frequently Asked Questions
Can a patient need more than one prior authorization?
Yes. A patient may need separate authorizations for different parts of their care. For example, they could need approval for diagnostic imaging and later need another authorization for a medication or procedure.
Can the same service require prior authorization for one patient but not another?
Yes. Prior authorization requirements can differ between health plans. This is why your team should verify the patient’s individual coverage instead of relying on what was required for another patient.
How do you know if something requires prior authorization?
Check with the patient’s health plan before providing the service or treatment. Many insurers have online tools or lists showing which services require prior authorization. You can also contact the health plan directly if you’re unsure.
