Understanding Prior Authorization

Prior authorization in health care is a requirement that a healthcare provider gets approval from an insurance plan before prescribing their patient medication or doing a medical procedure. Insurance providers use prior authorization to make sure that a specific medical service is needed and worth the cost, and that no duplicative services are being performed.
Payers use prior authorization as a way to keep healthcare costs in check. Terry discusses the Medicare, Medicare Advantage, and Commercial Plan terms with PAs and how to make it administratively manageable. Also, a coding question on Smoking Cessation.
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[@YvonneYoung-o1o]

I am a prior authorization specialist getting doctors to comply with the documentation necessary to establish medical necessity for a service being requested is the most difficult part of my job. It seems that some doctors allow their ego as a medical provider to supersede doing what is necessary to get paid. It is excellent compliance in documentation that affords some doctors to be awarded the gold card. Oftentimes it's the lack of amendments to previous doctor's notes that describe the current changes or new occurrences that result in denials on the first submission. This can lead to peer-to-peer reviews with the Medical Director taking time away from patient care. I have the hardest time getting Nurses and Doctors to understand this.

[@jenelscott7776]

Thank you for this info 🙏🏼