Prior authorization is a process that requires healthcare providers to obtain approval from Medicare before providing certain services. It involves submitting paperwork and documentation to justify the need for the service and adherence to specific criteria set by Medicare. Prior authorization aims to ensure healthcare services are medically necessary and cost-effective.
The background and definition of prior authorization in Medicare can be traced back to the Medicare Modernization Act of 2003. This legislation created the need for prior authorization for certain services to control healthcare costs and improve care quality. Prior authorization is a mechanism Medicare uses to limit the use of services considered not medically necessary or not covered by Medicare.
What Prior Authorization Can Mean to Beneficiaries
Prior authorization can significantly impact those who rely on Medicare for their healthcare needs. Healthcare providers must obtain approval for numerous services, including medications and medical procedures. This process can lead to delays in care, increased administrative work for healthcare providers, and expenses beneficiaries must pay themselves.
– 91% reported that prior authorization could lead to adverse clinical outcomes.
– 82% said prior authorization could lead to patients abandoning their treatment.
– 34% said that prior authorization led to a severe adverse event for a patient in their care.
