When your doctor recommends a medication, procedure or medical device, you're probably wondering if it’ll help, how much it’ll cost and how soon you can get it.
So, if your provider tells you they need insurance approval, it can feel like an unnecessary hurdle or delay.
That process is called prior authorization, and it's generally used for services or prescriptions that have high costs or are used often.
As a physician and clinical leader for a health insurer, I understand why this step can be frustrating. Insurance works by sharing financial risk among everyone with coverage, so everyone has a stake in using premium dollars wisely.
Prior authorization is one of the tools
we use to help make sure treatments are backed by medical evidence, cost-effective and covered under a member's benefits.
At BlueCross BlueShield of Tennessee, only a small share of services require this review. Last year, fewer than 5% of medical and behavioral health claims for commercial members and less than 6% of pharmacy claims required prior authorization. Even when it's required, many approvals happen automatically based on the information provided.
BlueCross doesn’t use automation to deny prior authorizations for eligible members. Requests that aren’t initially approved receive additional review, and any denial decisions are made by a board-certified physician for medical and behavioral health services or a pharmacist for prescription drugs.
Looking beyond the advertised promise
I often talk with people who've seen advertisements for treatments that promise impressive results. Many of those benefits are real. What gets less attention are the warnings, side effects and cases where a treatment may not work as expected or create added risks.
Prior authorization helps ensure those details are considered. A treatment that works well for one person may not be the best option for another because of a medical condition, drug interaction or safer alternative.
This review also considers claims, prescriptions and other care that may be relevant to the decision. That helps ensure important details aren't overlooked when coverage is determined.
Balancing access and affordability
Patients and their doctors make decisions about care. And most reviews confirm the recommended treatment or procedure is the best option. Other times, it may identify a generic medication that has been proven to work just as well at a lower cost or find that a treatment has been proven effective for one condition but not another.
Medicine continues to evolve as new therapies become available, and researchers learn more about what works for different conditions. Coverage policies need to evolve, too. We regularly review and update our policies to reflect advances in care, physician expertise and the latest medical evidence.
The goal is to keep pace with changes while helping health care remain affordable. As new treatments and drug therapies become available, costs continue to rise, with some treatments now costing hundreds of thousands oreven millions of dollars. Employers want to offer health benefits, and families want access to care. Both depend on the cost remaining within reach.
Still, the process isn't perfect. People are right to expect a process that's clear, timely and easy to navigate. Delays remain one of the biggest concerns people have with prior authorization.
Improving the experience
That's why insurers must keep improving it. At BlueCross, we've reduced or adjusted authorization requirements across several categories of care and continue to review where they're truly needed.
We're also using technology to help make the process faster. Nearly 40% of approved outpatient requests submitted through web-based channels receive an instant approval decision. For pharmacy reviews, the average turnaround time is less than two days, and most are completed within 24 hours.
If your insurer requests more information before covering a service, talk with your provider about the treatment, possible alternatives and what may be needed to complete the review. At BlueCross, we're committed to helping members navigate the process, understand their coverage and access the information they need through our app, online tools and customer service team.
Andrea Willis, MD, MPH, FAAP, is senior vice president and chief medical officer for BlueCross BlueShield of Tennessee.
This article originally appeared on Nashville Tennessean: What to know when your insurer asks for an extra clinical review
