What Prior Authorization Means for You
We all know insurance billing is challenging. You feel it as the patient with hoops to jump through to get reimbursements, approvals, and coverage. We experience it as physicians when insurance policies come between us and the care we recommend for our patients and when these hurdles take time away from our mission — to treat our patients.
We want you to know that we are working hard behind the scenes to help. We’ve added staff, processes, and advocacy to ensure you get the necessary medications at a reasonable cost. The bottom line: we are in this together.
Some background on prior authorization
Prior authorization is a process used by insurance companies to determine if a specific medical treatment, procedure, or medication will be covered. The purpose was originally to ensure that the requested treatment is medically necessary, cost-effective, and in line with insurance plans’ coverage policies. This process was created to control healthcare expenses for new and expensive therapies. Most medications were covered without this process.
Today’s reality
Unfortunately, over the last few years, the prior authorization process has been extended to numerous medications and has become a way for insurers to contain costs. Even old, effective, and generic treatments may be subject to this labor-intensive, unpredictable process. It requires extensive paperwork, correspondence, and phone calls, which can take several hours daily.
What this can mean for you
In addition to our staff jumping administrative hurdles behind the scenes at our office, patients often will not get the recommended prescriptions. Even after succeeding at getting prescriptions approved, it’s impossible to know how much the cost to patients will be. This can lead to treatment delays and even non-treatment, which may also cause poor health outcomes.
How we help
As experienced physicians working within changing systems for decades, we are prepared to advocate for our patients.
We’re on your side and are motivated to get you your treatment.
We’re working tirelessly on your behalf to take the burden off of you. Our process at SSDP has been made as efficient as possible. We’ve hired extra staff to support the increasing burden of paperwork and calls caused by prior authorizations. On average, physicians have 29 prior authorizations weekly, requiring about 15 hours.
Prior authorizations are taken care of promptly at our office. However, insurance company responses may take two weeks or longer.
Even approved medications require this process annually and any time patients change insurance plans.
We want you to know
“Doctors and patients are on the same side. We want our patients to get the prescriptions we recommend.” — Dr. Leera Briceno
There is no way to know which medications will be covered for each patient. We want patients to have affordable and effective treatments. However, there is no prescription-cost transparency. The cost becomes evident only after the pharmacy runs the prescription.
“Even for patients who have been previously approved, the prior authorization must be resubmitted every year. For unclear reasons, the medication is typically rejected the first time and requires a second set of forms. When my patient changed insurance, she no longer had access to the prescription that cleared her psoriasis and managed the pain of her arthritis.” — Dr. Edward Herman
What you can do
Prior authorization is a multi-staged process that can take days, weeks, and, in extreme cases, months. Despite our best efforts, there are frustrating delays for patients and physicians.
In most cases, if there has been no notification to you, it is due to delays on the insurance side. Please call us if you aren’t sure of the status of your application.
Patients notified about successful prior authorization need to confirm the insurance approval has reached their pharmacy. The pharmacy often lags in being notified.
The American Medical Association and American Academy of Dermatology will continue to advocate on your behalf. You can assist in advocating by reaching out to your Congress members and state legislators to let them know how this has impacted you. Share your story on fixpriorauth.org. Reform for the prior authorization process is long overdue.
Learn more:
Fixpriorauth.org (American Medical Association site with link to send your concerns to Congress)
AMA Video — What Doctors Wish Patients Knew About Prior Authorization
Any questions? Consult our office staff or one of our board-certified dermatologists. Please contact SSDP to schedule an appointment with any of our physicians.
