What Is Medicare Prior Authorization?

Michael T. Braden, May 7, 2024 GENERAL MEDICARE

What Does It Mean To Have Prior Authorization For Medicare?

WHAT IS PRIOR AUTHORIZATION FOR MEDICARE SERVICES AND PROCEDURES

Medicare uses Prior Authorization to ensure that certain medical services or prescription drugs meet specific coverage criteria before they are approved and paid for. Prior Authorization rules are implemented as cost-saving measures. Medicare wants to ensure that every Medical Procedure is medically necessary for the beneficiary's health.

Did you know that before a physician can provide services to a patient, it may be necessary to receive Prior Authorization Approval from Medicare? Your doctor can provide certain services; prior authorization from Medicare may be required. 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 APPROVAL IS JUST LIKE IT SOUNDS?

Prior authorization is a process in which your healthcare provider requests and receives approval from Medicare before they can be sure your plan will cover a service. 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 asks for approval before the procedure is performed.

Once the physician submits the request, Medicare will review the submission and determine 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 appeal the decision. However, a denial may result in the patient being responsible for 100% of the cost.

PRIOR AUTHORIZATION FOR MEDICARE PART A

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 itself. However, it is essential to understand who is responsible for submitting the paperwork, so that 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, home healthcare services

If prior authorization is necessary, the process is simple. Your Doctor or health care provider initiates the process by submitting the appropriate Prior Authorization Request Forms to Medicare. This includes an outline of the treatment plan that your Doctor has for you.

PRIOR AUTHORIZATION FOR MEDICARE PART B

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 in which you may need to get 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 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.

PRIOR AUTHORIZATION FOR MEDICARE PART D

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 helpful way to print the documents and take them to your doctor. Your doctor can help you correctly complete the form.

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

PRIOR AUTHORIZATION FOR MEDICARE ADVANTAGE PLANS

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 price 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 whether and when prior authorization is required. Your plan provider should also have downloadable forms 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 your stay at an SNF will be paid only if you use an SNF in your plan's 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 most frequent complaints among Medicare Beneficiaries who choose Medicare Part C over Original Medicare.

DO YOU HAVE TO GET APPROVAL FROM MEDICARE DIRECTLY?

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 ensure they have all the information needed for submission, and that everything is complete and correct before submitting.

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.

HOW MUCH TIME DOES IT TAKE TO GET AUTHORIZATIONS APPROVED?

The time it takes to receive a decision on your Prior Authorization Request varies based on the following: Medicare is usually swift (48-72 Hours), but if you have a Medicare Advantage plan, the decision may take much longer. You need to remember that Medicare Advantage Companies are operating "For Profit". Wait times for a decision are 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 necessary information to approve your case.

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

WILL I NEED PRIOR AUTHORIZATION FOR AN MRI OR A CT SCAN?

If the purpose of the MRI is to treat a medical condition, and all involved providers accept Medicare assignment, Part B would cover the inpatient procedure. However, a Medicare Part C beneficiary may need prior authorization to see a specialist, such as an orthopedist.

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.

WHAT ABOUT PHYSICAL OR OCCUPATIONAL THERAPY?

Most often, you’ll obtain prior authorization the same way, regardless of the service. Your doctor will document medical necessity and send forms to either Medicare or your plan for approval.

DO I NEED PRIOR AUTHORIZATION IF I NEED TO SEE A SPECIALIST?

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.

STILL CONFUSED ABOUT PRIOR AUTHORIZATIONS?

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