Whether you call it prior review, precertification, or prior authorization (PA), the practice is widespread and under attack. Almost every healthcare professional with experience with PA complains about the time required to respond to the request and the delay involved in getting treatment for a patient.
Prior authorization has been popular with the insurance industry because it works. By works, I mean it’s generally successful in its intended purpose of limiting unnecessary care by requiring the physician or prescriber to demonstrate the medical need for the prescribed treatment before it is approved for payment. The theory is that if the patient is truly in need of the proposed treatment, the physician will take the time to jump through administrative hoops to obtain it. If not, he/she will choose an alternative therapy. This is known as the sentinel effect, and in the initial stages, providers accommodated the process without much complaint. Read more >