Impact of Prior Authorization on Timely Patient Treatment

By molly watson


A good planned Prior Authorization program can lead towards improvised patient treatment access timely.

Payers use utilization management program in order to approve treatments such as pharmaceuticals needs, durable medical equipment, and medical devices.

Such programs include prior authorization processes, in which payers determine either they will reimburse providers for a treatment before it can be administered. It also involves step therapy, during which patients and providers consider less expensive treatment options before opting an intensive therapy, since these processes are necessary for cost containment.

Healthcare industry put patient needs at the forefront of care. American Medical Association (AMA) believes that prior authorization is an extra burden and restricts patients to have treatment on time.

AMA believes to make prior authorization a timely and fair process that will lead towards promised and improved patient care.

Timely access and reduced administrative work

Payers need to ensure that prior authorization and other administrative work is handled without any delay

To ensure patients have prompt access to care, utilization review entities need to make coverage determinations on time. Lengthy and complex processing times for PA can delay important treatment, which might lead towards medical complications for patients.

For timely utilization management programs need administrative efficiency and effectiveness. However, payers can minimize administrative load by using the right electronic transfers to conduct prior authorization reviews.

In case payers focus on reducing administrative burden, providers will be able to submit required PA materials more quickly, thus leading towards a faster treatment.

Encourage transparency in process

Payers need to have transparent information regarding which treatments are included in insurance plan and treatments which require prior authorization.


To promote provider and patient understanding and ensure effective clinical decision making, it’s very important that utilization review bodies provide specific justification for PA indicating covered alternative treatment solution and details for any available appeal options.

Rooting decisions in clinical validity

Providers choose the treatment option which is best suitable for a patient. However, cost remains an important element for healthcare. Therefore, prior authorization decisions should be based on clinical evidence instead of treatment cost.

Payers should also be flexible in coverage decisions, the organization wrote, because treatments are based on patient and provider needs.

Every medical condition requires a specific medical treatment. Existence of comorbidities and patient intolerances might lead towards availability of an alternative treatment.

Bottom line is an improved and better patient access to care. Since the healthcare industry continues to accept patient – centered care, both providers and patients are working together to make better healthcare decisions. Therefore, the burden on the payer in order to improve reimbursement treatments, making treatment available for patients without any delay.

Guarantee patient care continuation

Prior authorization doesn’t only delay patient treatment but it also interfere an ongoing treatment; specifically when patients switch payers. Therefore, healthcare continuity due to prior authorization becomes an extra burden.

To avoid the delay and complexity, payers should conform patients that they can receive treatments while undergoing review processes.

Moreover, patients should not be required to undergo repeated step therapy while changing health plans in order to avoid delay in treatment.

A set of pre-approved treatments that are a part of a health plan, should allow patients to continue the regimen until the start of a next year plan.



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