What is Prior Authorization?

Prior authorization is when your healthcare provider seeks your insurance company’s consent before obtaining a particular drug or procedure. It is also known as precertification, pre-approval, or predetermination.
If you don’t have this kind of authorization, your insurance may deny covering your treatment. Making you liable for the entire treatment payment. This can cost a lot of money, so knowing about prior authorization is essential.

Why do Insurance Companies Need It?

Insurance firms use prior authorization to ensure that the recommended medical services are necessary and cost-effective. Its core purpose is to keep healthcare costs in check. Insurance plans require prior approval to ensure that patients receive only the treatments they need.
This process can also avoid unnecessary expenses on costly treatments or drugs. Prior authorization helps to allow healthcare resources. This ensures that patients use expensive drugs and services appropriately only when needed.
This system has its controversy as well. Many opponents believe this system can delay necessary care and add more bureaucracy in health care management for physicians and health care professionals.

What is Medical Necessity?

Medical necessity is one relevant term that would relate to prior authorization. This means that the prescribed treatment or medication is necessary for your health. The insurers analyze if contemporary medical science backs the proposed treatment.
For instance, if you need a particular scan, your carrier may inquire whether you have had the same scan recently. They want to avoid unnecessary duplication, so each care test must be unique.

Knowing Costs

They also consider the cost of treatment. An insurer would require assurance that the prescribed medication or service is most economical available. A real-life example can illustrate this: if two types of medications are offered to treat the same condition. But one is much cheaper, the insurer is likely to ask whether it is necessary to use the more expensive option.
Sometimes, they require step therapy, meaning you must try the cheaper option before they approve the more expensive one. If it does not work, then they get to approve this one.

Continuous Care and Benefits

This does not mean prior authorization requires one-time approvals only. Prior authorization would allow the insurers to determine whether the treatments you receive are ongoing and appropriately justified. For instance, when you have been in physical therapy for several months, your provider may add that you require additional sessions. The insurer will want to know if the treatment works for you before they approve additional sessions.
If you are showing some progress, they may provide more sessions. However, if you’re not improving, they may seek a detailed report from your provider before deciding.

Which Medications and Services Need Prior Authorization?

Not all services or medications require prior authorization. Emergency services do not have to achieve prior approval due to the urgency of the time. However, most non-emergency services do.
Some types of drugs tend to require prior authorization more often. They include:

• High-cost drugs: If there exists another less expensive alternative, then the use of the high-priced drug might be considered, and supplementary justification might be required.
• Drugs with severe risks: Drugs that would cause serious side effects or have potential for abuse are those likely to have more requirements for approval.
• Medications for medical and aesthetic purposes: Take, for instance, weight loss drugs that qualify under a prescription condition, such as diabetes

Introduction to Medatron Prior Authorization Services

The tasks of prior authorizations are cumbersome for healthcare providers. That’s where Medatron comes in. Here, things’ complexity and process flow are streamlined and made more accessible.
Our team ensures that all needed documents get prepared and submitted with at least a two-day buffer period. Our proactive approach minimizes delays in treatment and the overall time that healthcare providers would need to manage away from proper patient care.

Effective Coordination with Insurance Companies

Medatron works with all insurance companies, both government and private. Our specialists ensure that medical billing complexities are dealt with and that all prior authorizations are obtained quickly and accurately.
Medatron Prior Authorization services include phone calls and online document submissions for quick approvals. The system warns the healthcare provider about authorizations requiring further review to avoid denial.

Why Medatron?

So why Medatron? The answers listed below must answer your selection process in choosing Medatron for your prior authorization requirements:

• Eligibility Verification: We verify patient eligibility and benefits before forwarding requests.
• Appeals: We help with the appeal process in case of denial of authorization.
• Follow-ups: We follow up with the status of authorizations to inform providers.
• Data security: We treat every piece of information as gold and deal with it according to regulations.
• Denial rate reduction: Our expertise results in fewer denied claims and better revenue for the practices.

Conclusion

Prior authorization is essential to healthcare as it impacts treatment access and cost. Also, knowing how prior authorization works will let you be in control, bettering your health outcomes.
With Medatron, services like these optimize your prior authorization process and reduce paperwork, improving productivity in healthcare providers’ business activities. We believe in and want our patients to have proper medication time while we support healthcare practices.
Improved communication with the insurers and fewer delays help us protect the patients and providers for satisfaction and better health outcomes. Contact us now if you want to learn how we can assist you.