CEO: Prior Authorizations
April 05, 2023
by Scott Thoreson, CCMH Chief Executive Officer
In the world of health care, we are hearing a term much more frequently now than we have ever heard it in the past, and that term is “prior authorization.” It might be you have encountered this term and perhaps it has delayed you or kept you from obtaining a specific test, treatment or drug.
Health care is tremendously expensive, as we all know, and those that pay for the cost of health care, such as the federal and state governments, health insurance companies and companies that are associated with self-insured businesses and organizations are all looking to save money. In fact, CCMH changed the company that oversees our employees’ claims last year and this move has triggered more “prior authorizations” for our own employees and their dependents who are on our health insurance plan.
It is important to share that we, as a provider of health care services, are not the ones requiring patients to become prior authorized. It is a condition of the insurance provider that is footing the bill for the service. In some cases, there is a natural progression the insurance company wants followed to possibly reduce costs. Take for example someone suffering back pain and they feel they need a MRI test. Many insurance companies first require the patient participate in some physical therapy for a period of time to try and avoid the expense of the MRI, perhaps it won’t be needed, or perhaps time alone will help address the bad back problem.
Most, if not all, of our providers bemoan the need for prior authorizations as they are conservative in their treatment and feel that, if a patient needs something, they really need something. Of course, in different parts of the country, this kind of conservative medicine is not always practiced and all health care providers are required to follow identical policies and procedures. At CCMH, we do the best we can to quickly address prior authorizations so we can hopefully continue a plan of treatment for a patient with minimal disruption. In the above mentioned example, if we were to provide a MRI for the bad back patient, without the proper authorization, it would be considered non-covered and we would not be able to charge for it at all.
Our billing department and the staff responsible for scheduling various tests that require a prior authorization are seeing more denials than they have ever seen before. In many cases, there is an appeal mechanism, but this takes time and takes the provider away from the exam room taking care of patients. The time spent on appeals also delays treatment for a patient’s condition. Health care providers are sharing specific stories with our contacts with the Missouri Hospital Association who are compiling these stories to share with our state legislators and personnel in Jefferson City. From our perspective, some insurance companies are more receptive than when considering and processing prior authorizations in a timely manner.
I strive to write articles that help educate the readership on various timely topics and I hope this article has provided insight into the term “prior authorization” and if you have a certain topic you would like us to discuss please reach out to us at email@example.com. I wish you good health!
More in this Series:
CEO: Staff Shortage and Open Positions (Published February 8, 2023)
CEO: End of Year 2022 (Published December 14, 2022)
CEO: Purpose of the Foundation (Published November 10, 2022)
CEO: Health Insurance Portability and Accountability Act (Published September 28, 2022)
CEO: CCMH Providers (Published August 24, 2022)
CEO: Financial Assistance (Published July 20, 2022)
CEO: Social Determinants of Health (Published June 29, 2022)
CEO: National Hospital Week (Published May 11, 2022)
CEO: Why Healthcare is Expensive (Published May 4, 2022)
CEO: A Hospital is Still a Business (Published March 16, 2022)
CEO: Different Types of Hospital Ownership (Published February 1, 2022)
CEO: Holiday Message (Published December 20, 2021)