Prior Authorization (PA) is a business term, but most practicing physicians know this phrase all too well. Before providers can perform an advanced imaging study, prescribe certain medications, or order some diagnostic tests, they must first obtain authorization from a third party. Without authorization, the insurance company will not pay for the service. And without that all-important authorization number, imaging facilities, sleep centers, and cardiologists will usually not even schedule your patient’s scan or cardiac test.
Is the Prior Authorization process performed by the Insurance Company or someone else?
Very few insurance companies perform their own prior authorization functions. This process is usually outsourced to a third party, called Radiology Benefits Managers (RBM). These third parties contracts with not only insurance companies but also with state Medicaid plans and Medicare Advantage plans. To obtain authorization for advanced imaging, providers (physicians, nurse practitioners, and physician assistants) must interact with the RBM. Providers needing authorization for medicines must interact with Pharmacy Benefit Managers.
In the early days of prior authorization, only a few imaging studies required PA, including CT, MRI, PET scan, and myocardial perfusion imaging. Over time, some insurance companies and health plans required prior authorization for other diagnostic testing, such as Ultrasound, Doppler, OB-ultrasound, sleep studies, echocardiography, genetic testing, or cardiac catheterization. Treatments such as joint replacement, pacemaker insertion, radiation therapy, and chemotherapy were also added to the list of required authorization. As the lists get longer and the number of patients requiring prior authorization grows, it is unlikely that prior authorization is going away.
Is there anything physicians can do to lessen the PA burden?
Learning how to navigate the PA system and using that knowledge to obtain quick and reliable authorization will pay dividends and save physician costs, time, and stress. PA is not going to disappear but physicians can learn to make the process quicker and less frustrating.