Insurance companies (IC) utilize the prior authorization (PA) process to ensure that a given service meets their contractual terms with their customer (your patient). The process, done via an online portal, email, or by call, seeks additional information from the provider (you) to determine the medical necessity (or eligibility) of a given procedure being recommended for their client (your patient).

Any IC may require a PA for specific events. The events and approval requirements vary between companies. A PA may be necessary for surgeries, procedures (such as X-rays, scans, labs, etc.), consults with other providers, medications, or treatment plans. 

As the name implies, prior authorization must be completed before treating the patient. Failure to do so will often result in a denial of payment to the provider and perhaps financial implications for the provider or patient.

Insurance carriers are an integral component of the US healthcare reimbursement triad, which consists of patients, providers, and ICs.

The IC has two inherent business goals: first, to collect money from premiums, and second, to pay claims according to their contractual obligations with their customer (your patient). If they deny a PA, the insurance company pays less in claims and makes more money.

Here are the basic steps:

1.      Verify the patient’s insurance coverage.

2.      Check the IC PA procedure listing to determine if a PA is required.

3.      Determine the IC required documentation and submission method if a PA is needed.  At a minimum, IC will often require the most recent office note and may indicate other supporting documentation. 

4.      The IC often defines an expected timeframe for submission and responses.  Make sure to work within those time frames, or your PA may be denied.

5.      As you do this process, you will find patterns of what documentation the IC PA process is looking for approval (it is often not clearly defined by the IC; trial and error are required on your part). Vendors of products or services you are obtaining the PA for may be good resources to determine what is necessary to approve the IC PA process.

Special note regarding OBH office notes, especially when requests are being made for PA, make sure documentation includes:

1.      History (medical, fracture, family, surgical)

2.      If a fracture is involved, what is the mechanism, and what was fractured?

3.      Test results (labs, BMD/T-Score, TBS, etc)

4.      Risk Scores when appropriate (FRAX, Garvan, etc)

5.      Diagnosis (often multiple)

6.      What is your treatment plan?  Be specific as to procedures or treatments.

7.      Expected duration of treatment

8.      Are there studies, guidelines, or position statements to support your request, and from whom?

Insurance carriers are critical, but your relationship with the IC will often feel more adversarial than acrimonious. They will not make assumptions or connect the dots to follow your treatment plan or logic.  It becomes the classic “if it’s not written, it doesn’t exist.”

As you go through this process, remember that you are your patients ‘advocate on their pathway to high-quality care.  The IC is most likely not as interested in your patient’s outcome as you are.