PA or Prior authorization is a process demanded by insurance companies to ascertain if a recommended service or procedure will be covered by the insurance company based on the patient’s eligibility and policy coverage.
With healthcare prior authorization, the dental team will get feedback from the insurance company on whether the recommended service or procedure will be paid for in full or only partial coverage will be possible. This process is needed for some services or procedures before they are rendered to the patient.
The process of healthcare prior authorizations involves a set of steps. Initially, the dental practice will need to perform patient eligibility verification to confirm whether the individual qualifies for the recommended treatment under their insurance plan. Then, the practice should determine if prior authorization is required. If so, the practice must submit all relevant information, including the patient’s dental history and other supporting documentation, to justify the necessity of the proposed treatment.
The team also needs to submit supporting documents that justify the requirement and extent of the recommended procedure or treatment. Once the prior authorization criteria for the submitted case have been met, the insurance company approves the request and reimburses the treatment cost based on the terms of the patient’s insurance policy.
Insurance companies mandate the need for prior authorization as a means of controlling and justifying treatment and expenses. It controls access to medication or procedures and ensures that procedures and medication are provided to patients who need them.
The insurance companies thus ensure that recommended treatments are cost-effective, appropriate, and safe for the patient, and all the necessary criteria are met.
Treatment necessity
Being necessary from a dental practitioner's perspective means that one needs to administer a particular procedure or service that one is proposing. The insurance company is trying to determine if the criteria for such a proposed recommendation are being met. The insurance company is scouting for factors or data that suggest whether the treatment recommended to the patient is backed by evidence and a thorough evaluation.
It also needs to confirm that the procedure or tests are not being duplicated. For example, a patient might visit more than one specialist or practice. If one provider has ordered a scan, then the same scan recommended by another might not be needed. For such instances, an insurance company will not pre-authorize the second scan unless necessary.
Costs
Any insurance company wants to be sure that a proposed procedure makes financial sense for having it. The procedure recommended should be the most economical alternative for the patient. If two alternative drugs are being suggested for a condition, then the practice must suggest the cheaper alternative if the efficacy of both is the same.
There can be cases when an insurance company mandates the need for step therapy. This means that an insurance company will pay for an expensive alternative only if the cheaper one is not effective. For example, an insurance company will agree to an MRI only if the practice proves that an X-ray will not be adequate.
Benefits to the patient
An insurance company would also need to ensure that the prevailing course of treatment for a patient is helpful. If a procedure recommended to a patient and authorized by the insurance company has not worked, the insurance company might not allow the practice to repeat the procedure.
Emergency services and procedures do not require prior authorization. Time is of the essence in such cases, and the practice will not have adequate time for documentation and approvals.
An insurance company may need some dental procedures and services to get prior authorization before administering the same. This is mainly when there are complexities in the procedures recommended or if the associated costs are high.
Some examples of procedures that need prior authorization include orthodontic treatments such as braces and aligners. Prior authorization is needed for bridges, crowns, bridges, and dentures.
Surgical extractions that include difficult extractions may need prior authorization. Dental implants are costly procedures and usually need prior authorization. Periodontal surgeries, such as flap surgeries or gum grafts, must be cleared by the insurance company before treatment begins.
If a practice or hospital prescribes medication, the insurance company will determine if the drugs or medication recommended are vital and are an optimal option for the current state of the patient. Depending on the patient's case, the insurance company may sanction a short-term supply of the medication.
Drugs with serious risks, drugs that can cause addiction or lingering side effects, expensive drugs, etc., generally require prior authorization. Drugs recommended for medical and cosmetic reasons also need to be sanctioned by the insurance company.
Prior authorization is a time-consuming process and is dependent on the urgency or criticality of the need for treatment. It can also be dependent on the state where the patient lives and the type of insurance policy and coverage.
For state-regulated health plans, the guidelines for prior authorization differ from state to state. The government at the federal level also modifies rules and guidelines to streamline the prior authorization process for plans such as Medicaid. One needs to note that marketplace plans are subject to state rules for prior authorization and are bound by state regulations.
It has been proposed that in the coming year, new rules may require insurance companies to respond within 7 days to a non-urgent prior authorization request, as against the present timeline of within 14 days. Insurance companies would have to respond to an urgent authorization request within 72 hours.
Prior authorization implies that a dental practice, healthcare provider, or hospital gets prior approval from the insurance company for drugs, procedures, or treatments recommended for a patient. Various rules for prior authorization are prevalent depending on the insurance company and the insurance plans. Dental practices, including those partnered with Capline Dental Services, must follow the mandated guidelines for prior authorization to ensure claims are processed and approved without delay, allowing patients to receive the most appropriate and effective procedures or services available.
