Have A Plan If You’re Denied
Talk to your provider and their office about what you will do if your prior authorization request is denied. You and your provider may choose to appeal the decision if you think the prior authorization denial was not justified.
If your prior authorization request is denied, the first step is to find out why. If a simple error was to blame, it might be a quick fix.
After you’ve checked all the paperwork that was submitted to make sure nothing is missing and all the information is correct, you might want to see if there are other things you could add that would help prove the care you’re asking for is needed.
For example, your provider might know of research that would be helpful to include.
Medicare And Prior Authorization What You Need To Know
Owner/Agent at Peachtree Insurance Advisors
The purpose of this article is to explain how Prior Authorization works with Medicare. This is an important subject because the prior authorization process can factor into your decision about which type of Medicare plan you choose. Additionally, if you enroll in a plan that requires prior authorization, then it is vital to know how the process works, especially if your request is denied.
What Is Medicare Prior Authorization
There are many confusing terms that are used when discussing Medicare health insurance, among them is the term prior authorization. This term refers to the requirement which states that a healthcare provider must obtain approval from the Medicare program itself in order to provide a given medical service or treatment. In other words, it ensures that benefits cover treatment that is expressly pre-approved by Medicare.
Of course, this begs the question: Does Medicare require prior authorization? Well, like many things in the world of insurance, the answer is a bit more complicated than a simple yes or no. In actuality, whether prior authorization is specifically required for you, the Medicare beneficiary, to receive certain treatment is entirely dependent on the treatment or service itself and the level of Medicare coverage you have.
Lets take a look at this question in more detail by breaking down the specifics of prior authorization requirements by the different parts of Medicare.
What Are The Negative Effects Of Prior Authorization
- Perhaps the most significant negative effect is that prior authorization delays patient access to care. It adds a speed bump to the patient journey, and can lead some patients to forgo treatment.
- In fact, 75% of physicians participating in an AMA survey reported that issues related to the prior authorization process can cause patients to abandon their recommended course of treatment. In that same survey, 28% of physicians reported that preauthorization has led to a serious adverse event for a patient in their care.
- The administrative burden from prior authorization distracts clinicians from practicing medicine and contributes to the growing epidemic of physician burnout.
- The unstructured and unpredictable nature of preauthorizations can wreak havoc on the normal administrative workflow of a practice. In fact, many practices have to add or repurpose staff expressly to deal with prior auths. These inefficiencies and the additional overhead required to deal with them can strain already dwindling margins and overextend office personnel.
Sometimes prior authorization requirements are not determined until after treatment is complete. This results in payers withholding some or all of an expected reimbursement. If this is the case, providers will often have to pursue payment from patients directly, a strategy that often results in practices writing off uncollectible revenue as bad debt.
Does Medicare Require A Referral To See A Specialist
Although a primary care doctor can help you navigate many of your healthcare needs, you may have medical conditions that require the care of a specialist. Understanding when a specialist should be consulted and whether or not your Medicare benefits provider requires a referral beforehand can help you streamline your access to care.
Determining When to See a Specialist
The function of a primary care physician is to help you establish health needs and then help you maintain common health goals and preventive care. An appointment with your primary care doctor is typically your first step in addressing any chronic or acute symptoms.
While they may offer an initial diagnosis or order certain tests to confirm or rule out any medical condition, they are not always trained or experienced to address more complex health needs. In those situations, your primary care doctor will refer you to a specialist.
According to the Association of American Medical Colleges , there are over 120 specialty and subspecialty branches of medical practice. Their focus can be targeted on a disease or group of diseases, a specific organ or system of organs within the body. Depending on your medical needs, you may be referred to more than one specialist as a treatment plan is developed.
Original Medicare Referral Requirements
Medicare Advantage Plan Referral Requirements
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Referrals & Advance Approvals For Services
If you need certain types of covered services or supplies, you must get approval in advance through your Primary Care Physician .
When your PCP thinks you need specialized treatment, he/she will either give you a referral to see a specialist or certain other providers in our network, or will request a prior authorization from the Health Plan on your behalf.
It is very important to get a referral or prior authorization from your PCP for the services and items listed below that require it. If you dont have approval in advance for services or items that require a referral or prior authorization, you may have to pay for these services yourself.
You can get services such as those listed below without getting approval in advance from your PCP:
Your PCP can issue a referral for the following listed services:
Your PCP will need to submit an authorization request prior to the following services being rendered :
- Acute Rehabilitation Facility
- Ambulatory Surgery Center for Blepharoplasty, Podiatric Surgery, Reduction Mammoplasty, Rhinoplasty, Septoplasty, Vein treatments, Ocular Surgery, Pain Management Injections, Plastic Surgery only
- Clinical Trials Not Approved by Medicare
- Cosmetic Procedures
- Any service in an Outpatient Hospital
- Pain Management
- Radiology: PET, Pill or Virtual Endoscopy
- Rehab Cardiac/Pulmonary/Respiratory
- Rehab any outpatient hospital and any office therapy > than 10 visits.
- Skilled Nursing Facility
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How Prior Authorization Can Impede Access To Care In Medicare Advantage
While Medicare Advantage plans are required to cover the same health services as Original Medicare, they are not required to offer the same level of provider access and can impose coverage restrictionslike prior authorizationthat require enrollees to take additional steps before accessing prescribed care. If a service is covered with prior authorization, enrollees must get approval from the plan prior to receiving the service. If approval is not granted or sought, the plan generally will not cover it.
A new analysis from the Kaiser Family Foundation looks at the prevalence of prior authorization in MA and found that many plans utilize this flexibility: 80% of MA enrollees are in plans that require prior authorization for at least one Medicare-covered service. Original Medicare, in contrast, does not require prior authorization for the vast majority of services, making this an important distinction between the two coverage options.
In some instances, prior authorization may be an appropriate utilization management tool. In particular this is true when both beneficiaries and providers are likely to benefit from advance knowledge of Medicare coverage. However, MAs broad application of prior authorization can impede access to care.
In such situations, there is minimal value to beneficiaries or providers in procuring pre-service determinations. Instead, these requirements can often create barriers that may delay or prevent timely access to needed, affordable care.
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Original Medicare Medicare Supplement And Prior Authorization
The Social Security Act didnt require any form of prior authorization for Medicare services in the past. However, the law was altered to allow prior authorizations for specific services and items, such as durable medical equipment.
Although these changes were made to the act, prior authorization will only be necessary with Original Medicare in exceedingly rare circumstances. Medicare Part A rarely requires prior authorization as an inpatient. However, if you must have prior authorization, you would obtain the needed forms and submit them to Medicare.
Medicare Part B may require prior authorization whenever you are administered a specific drug in an outpatient facility. Some medications require your physician to submit a drug prior authorization form, which your physician would provide. Once the form is approved, Medicare will provide its share of coverage.
Overall, when you only have Medicare Part A and Part B, you wont have a network of providers, you can visit any hospital outside the state that accepts Medicare, and a referral is not needed to see a specialist.
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What Are The Rules Of Prior Authorization
Health plans each have their own rules in terms of what services need prior authorization. In general, the more expensive the procedure, the more likely a health plan is to require prior authorization. But some services will require prior authorization under one health plan and not under another.
In effect, a pre-authorization requirement is a way of rationing health care. Your health plan is rationing paid access to expensive drugs and services, making sure the only people who get these drugs or services are the people for whom the drug or service is appropriate. The idea is to ensure that health care is cost-effective, safe, necessary, and appropriate for each patient.
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What Is A Medicare Prior Authorization Form
- Medicare beneficiaries are sometimes required to obtain a prior authorization form for certain prescription drugs or medical services. We provide links to Medicare forms and explain why you might need them.
Prior authorization is a type of rule that requires a health care provider to get approval from Medicare before delivering a particular service, prescription drug or item to a beneficiary.
You dont typically need to get a Medicare prior authorization form, as your doctor, provider or pharmacist should be able to submit the form to Medicare on your behalf.
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How Does Prior Authorization Help Me
The prior authorization process can help you:
- Reduce the cost of expensive treatments and prescriptions by first requiring you to try a lower-cost alternative
- Avoid potentially dangerous medication combinations
- Avoid prescribed treatments and medications you may not need or those that could be addictive
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What Information Does A Referral Include
The referral should include:
- the date of the referral
- the signature of the referring practitioner
You can choose the individual specialist you want to be referred to or ask your doctor to recommend someone. The doctor can address it to a particular person or make a general referral without using the name of the specialist
Medicare Announces Prior Authorization Requirement
Radiologists who perform venous ablation in a hospital outpatient department are now required to obtain prior authorization before performing such services on Medicare patients. This new requirement became effective for services performed on or after July 1, 2020, and physicians were notified by letters from the Centers for Medicare and Medicaid Services late in June. The prior authorization requirement was included in the 2020 Hospital Outpatient Prospective Payment System Final Rule, and encompasses the following procedures that might be performed by interventional radiologists:
Chemical destruction of incompetent vein of arm or leg, accessed through the skin using imaging guidance
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How Are Claims Edits Different From Prior Authorizations
Payers can create electronic claims processing rules to enable automated determinations. For instance, if treatment associated with childbirth is recommended for a male patient, it can be easily flagged as erroneous and be denied. This would be an example of a claims edit.
However, medical decisions can be complex and not easily distilled into an if this, then that computational query. For the many care decisions that fall within a gray area, a claims edit will not suffice. These scenarios, where a determination of medical necessity is more nuanced, will often require prior authorization.
Open Enrollment For Medicare Part C
Medicare Part C open enrollment runs from October 15 through December 7. Some Medicare Part C plans require referrals. These plans follow the HMO or POS style of managed care.
These methods use the primary care physician to provide initial treatment and to make referrals to in-network resources.
In the case of POS style plans, the primary care physician can also make referrals to outside resources and the insurance will pay its agreed share of coinsurance. During the open enrollment period, subscribers can perform the below-listed actions on Medicare C -Medicare Advantage Plans.
- Switch plans from a currently subscribed Medicare Advantage plan to a different Medicare Advantage plan.
- Change from a Medicare Advantage Plan with or without referrals to Original Medicare.
- Change from a Medicare Advantage with no drug coverage to one that has drug coverage.
- Change from a Medicare Advantage Plan with drug coverage to one that does not have drug coverage.
- Switch from an HMO-style plan with referrals to a PPO style plan with no referrals.
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Who Is Responsible For Obtaining Prior Authorization
The healthcare provider is usually responsible for initiating prior authorization by submitting a request form to a patients insurance provider. As mentioned in the How does prior authorization work? section above, this will then often prompt a time-consuming back and forth between the provider and payer. In many cases, the licensed provider is required to sign the order, referral, or requisition before the payer will accept the authorization request.
It is also incumbent on patients to understand if preauthorization is required and if it has been approved before services are rendered.
Items And Services Requiring Prior Authorizations
Authorization numbers are not required for the following the service can be completed with a referral or an order from your primary care physician or specialist:
- Please download and review the Medical Services that Require Prior Authorizationlist.
- All procedures or surgery that has CHP clinical criteria requires review and an authorization at any location. See a listing of Capital Health Plan Clinical Criteria on the Medical Policies page.
The following are just a few of the services that have clinical criteria and require a review and a prior authorization:
- Please download and review the Medical Services that Require Prior Authorization list.
- Certain medications when obtained under the medical benefit, refer to the Medication Center for more information.
Contact Capital Health Plans Member Services Department for further information on which local participating practitioner services still require an authorization
Dialysis services received outside of Capital Health Plans service area may necessitate receiving services from a facility other than DaVita you should work with your local DaVita facility to coordinate these services prior to leaving the service area.
You and your primary care physician have access to Capital Health Plans utilization management clinical criteria through CHPConnect. You may also request a list of Capital Health Plans clinical criteria by contacting the Member Services Department.
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