With 알바 insurers increasingly using Step Therapy and Prior Authorization to manage costs, understanding the details of Step Therapy is critical to Prior Authorization Specialists, Medical Science Liaisons (MSLs), and Market Access Specialists. Health insurers use prior authorization (PA) to confirm that a specific medication, procedure, or treatment is medically necessary before the specific medication is done or prescribed. Although widely implemented as a cost-containing measure, prior authorization (PA) is an extensive and time-consuming process for providers, patients, pharmacists, and drug benefit plans.
Prior authorization (also called pre-authorization and pre-certification) refers to the health plans requirement that patients receive authorization to receive health services or medications prior to the delivery of care. PAs require patients to get authorization from the payer before coverage, that is, payment, is provided for the specific medical service (medication, diagnosis, imaging, etc.). The American Medical Association defines prior authorization as any process where physicians and other providers of care must obtain advance authorization from the payer to receive payment coverage prior to delivery of any particular service to the patient.
Known as pre-approval, prior authorization, or prior certification–or shortened as pre-auth or PA by some insurers–prior authorization will determine if a procedure, prescription drug, durable medical equipment, or other products or services will be covered. Although it is a lengthy process, the end goal of prior authorization (PA) is to optimize patients outcomes, making sure that they get the most appropriate medications, reducing waste, errors, and unnecessary use of prescription drugs, and keeping health care costs under control.
Not only is prior authorization cumbersome, unpredictable, and time-consuming for physicians, but it can cause detrimental delays in patients receiving needed care. To help mitigate delays for patients, it is critical for physicians to review their prior authorization requirements prior to providing services or sending a prescription to a pharmacy. These lengthy wait times adversely affect the patients experience and care, and for many practices, the burden of prior authorization (PA) has led to the withdrawal of preferred therapies for a different medication from their formulary.
While PAs may delay appropriate care by 5-10 days, sliding-scale therapies may delay optimal treatment by weeks to months. If the patient has not attempted step therapy, a payer may refuse to cover and require a prescriber to modify a prescription or submit a Step Therapy Exemption Request Form.
Even when a practice makes a prompt submission of a request, an insurance company can still ultimately deny payment for prescribed medications or treatments. When patients visit the pharmacy to fill their prescription, they are often told their insurer will not cover the drug if the doctor does not get an authorization. With healthcare coverage, insurers are in greater control of what prescriptions they will cover; they may offer higher-priced medications to those who really need them.
With Medicare Advantage, the medical plans and providers are typically paid based on the shared-risk model, or the total-risk model, meaning that they are paid an upfront amount to run a patients care, giving them an incentive to keep patients healthy and out of the hospital.
What makes Medicare Advantage plans worse is that they come with greater restrictions than Original Medicare in terms of what doctors and medical facilities you can use. These packaged policies cover Medicare Part A (inpatient care and hospitalizations), Part B (outpatient care) and often Part D (prescription drug coverage) all under one plan.
With an MA plan, you get the same level of coverage provided by Original Medicare Parts A (hospital insurance) and Part B (medical insurance) plus additional benefits offered through the MA plan. Some plans also cover the premiums for your Medicare Part B, so you do not incur any extra costs. Compare the annual deductible, which is the amount you have to pay for medical care or prescription drugs before your Medicare plan starts paying.
If you think that the drawbacks of Medicare Advantage outweigh the benefits of Medicare Advantage, explore alternative coverage options, comparing the best Medicare Supplement plans for lower healthcare costs, and researching the best Medicare Part D plans for finding out how to get the lowest-cost prescription drug coverage. Unfortunately, with privately managed Medicare Advantage plans, the health care providers within your network can change during the year, potentially creating a gap in care. With some Medicare Advantage plans, beneficiaries are required to get prior approval or authorization before seeing a specialist, another limitation that does not generally exist with Original Medicare.
A recent report by the U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG) found that 13% of the denials of prior authorizations from Medicare Advantage plans were for benefits that would have been covered otherwise under Medicare.
The Mental Health Parity and Addiction Equity Act (MHPAEA) requires for-profit insurers, employer-sponsored plans, and some Medicaid plans to document use of prior authorizations for covered services, including medical and behavioral health services. Patients can wait days, weeks, or months to have an appointment for an essential test or medical procedure, as physicians must first get a similar authorization from an insurance provider. If your health care team can demonstrate compelling evidence that the treatment is medically necessary, an insurer can approve a claim.
The provider or healthcare providers staff initiates a prior authorization, checks for requirements from your insurer, contacts your healthcare insurer, or receives any special forms needed to meet the requirements of a prior authorization.
Pharmacy benefit managers (PBMs) and payers (private and public health insurers) insist that stepped-up therapies are essential for controlling healthcare costs.5 While payers maintain that stepped-up therapies are not harmful to patients, physicians, patients, and pharmacists disagree.