WHAT IS MEDICARE PRIOR AUTHORIZATION

Prior Authorization is used by Medicare to ensure that certain medical services or prescription drugs meet specific criteria for coverage before they are approved and paid for. Prior Authorization rules are put into place as cost savings measures.  Medicare simply wants to ensure that every Medical Procedure is medically necessary for the beneficiary's health.

Did you know that before a physician is able to provide services to a patient; it may be a necessity to receive Prior Authorization Approval from Medicare. Your doctor can provide certain services, prior authorization from Medicare may be necessary. Depending on the Medicare plan you are enrolled in, you might need prior approval to see a specialist, have a procedure, or receive certain medications. 

Prior authorization is a process, in which your healthcare provider requests and receives approval from Medicare before they can be sure a service will be covered by your plan. This requirement is to ensure the services or medications you receive are medically necessary and appropriate for your condition. 

Typically, prior authorization is required for services or medications that are either A) Expensive, B) A procedure that is categorized as being an Elective Procedure, and may not be Medically Necessary, or C) a Procedure that is deemed as being overused by Medicare, based on Millions of Claims.

The idea and concept are simple enough, your Doctor or NP submits documentation to Medicare to make sure that Medicare knows that your request is Medically Necessary, and; asking for approval before the procedure is performed.

Once the doctor submits their request, Medicare will review the submission and decide whether to approve or deny coverage. If approved,  Medicare will cover its portion of the cost of the service or medication. 

If the prior authorization is denied, the patient or healthcare provider may have the option to appeal the decision. However, a denial may also end in the patient being responsible for 100% of the cost if the appeal is denied. 

95% of the time, PA (Prior Authorization) is not necessary; if you are admitted to a Hospital. But, if you must submit a prior authorization for a Part A covered service, you can obtain the forms to send to Medicare from your hospital or doctor. Often your hospital will send the documents themselves. But it is important to understand who is responsible for sending the paperwork, so the responsibility does not slip through the cracks. 

Examples of Medicare Part A. Services that may require prior authorization include: 

•  Care at a Skilled Nursing Facility (SNF) and/or Rehabilitation Facility 
•  Care or Procedures at an In-Patient Hospital
•  Medicare- At-Home, ho,e healthcare services

If prior authorization is necessary, the process is simple. Your Doctor or Health Care Provider starts the process when they submit the proper Prior Authorization Request Forms to Medicare. This includes an outline of the treatment plan that your Doctor has for you.

As part of Original Medicare, you’ll rarely need to obtain Prior Authorization (PA) for Medicare Part B services. However, there are a few instances where you may need to receive approval before receiving care. Medicare Part B covers the administration of certain drugs when given in an outpatient setting. 

Some prescription drugs you receive may require your doctor to submit a Part B  Drug Prior Authorization Request Form. Your doctor will provide and complete this form with detailed information regarding why the medication is necessary for your diagnosis. Once the request gets approved, you can begin receiving the medication. One medication that comes to mind is Evenity, it is a year-long commitment and Evenity is the only known drug to help to regrow bone density.  This is primarily for women who have been diagnosed with Osteoporosis. There are other examples such as newly released or Experimental Drugs for Dementia.

Often, some Medicare Part D Prescription Drug Plans can require prior authorization for coverage on specific drugs. Different policies have varying rules, so you’ll need to contact the carrier directly to confirm coverage. 

Most Part D plans have forms you can download online. The online option is a useful way to print the documents and take them to your doctor. Your doctor can help you correctly complete the form. 

Also, recipients may directly contact their Part D plan and ask for a mail-in form. You can find the number for Member Services on your plan’s member ID card. 

To obtain out-of-network, specialist, and emergency care, Medicare  Advantage recipients may need prior authorization. Unfortunately, if  Medicare doesn’t approve the request, the Advantage plan typically doesn’t cover any costs, leaving the full cost up to you. 

In 2021, over 35 million Prior Authorization requests were submitted on behalf of Medicare Advantage plans. The services most often requiring prior approval are durable medical equipment, skilled nursing facility stays, and Part B drugs.

However, each Medicare Advantage plan is different. If you are enrolled in a Medicare Advantage plan, contact your plan provider to determine if or when prior authorization is necessary. Your plan provider should also have forms you can download online outlining your covered services. 

*Note: Many Medicare Advantage Plans do not have enough Skilled Nursing Care Facilities in their Networks, or; you do not get a good vibe from them.  If this happens to you, remember that you will only have your stay at an SNF paid for, if you use an SNF in your plans network.  If you go outside of your plan's network, you will most likely be responsible for paying for your stay out of pocket.  This is one of the largest complaints from Medicare Beneficiaries who choose Medicare Part C over Original Medicare.

Refer to your plan documents, including the drug formulary, to see if your treatment requires approval. This information should be on your plan’s website. The Medicare & You handbook also contains more information. 

Your provider is responsible for requesting permissions. Please, make sure to give them all the information they need for submission, ensuring that everything is completed and correct before submitting it.. 

If your provider believes your treatment is medically necessary,  they can contact your plan and request an exception if you get denied.  The provider must support the request with a statement. Once approved,  your plan pays without prior authorization. 

The amount of time it takes to get a decision on your Prior Authorization Request will vary based on the following: Medicare usually is very quick (48-72 Hours), but; if you have a Medicare Advantage plan, they can take much longer to give their decision. You need to remember that Medicare Advantage Companies are operating "For Profit". And the wait times for a decision are the longest during the 4th Quarter.

For expeditious authorization, your doctor must provide detailed information, explaining exactly why the treatment is necessary. Providing as much detailed information as possible will ensure the reviewer has all the information necessary to approve your case. 

Missing information, diagnosis codes, or reasoning may delay your authorization and could even result in a denial. 

If the purpose of the MRI is to treat a medical issue, and all providers involved accept Medicare assignment,  Part B would cover the inpatient procedure. But, a Medicare Part C beneficiary could need prior authorization to visit a specialist such as a Orthopedists.

If your CT scan is medically necessary and the provider(s) accept(s)  Medicare assignment, Part B will cover it. Again, you might need prior  authorization to see an out-of-network doctor if you have an Advantage  plan. 

Most often, you’ll get prior authorization the same way, no matter the service.  Your doctor will document medical necessity and send forms to either  Medicare or your plan for approval. 

If you have chosen a Medicare Advantage Plan, you may need to have a referral to see a specialist.  If on the other hand, you have Original Medicare, regardless of whether or not you have a Medicare Supplement, you can see any doctor who accepts Medicare, and nearly 94% of all doctors in America accept Medicare.

We have done our best to inform you all about Prior Authorizations in this article. But, we know for many people, Medicare is still very confusing.  So if you are still confused, or would like additional clarification on the Prior Authorization process, or with anything related to Medicare please feel free to email me directly at mike@bradenmedicare.com.