Prior Authorization

The plan will pay some things without question as long as your primary care doctor orders it.

For other things, the doctor must call the plan ahead of time to get permission or else the plan will refuse to pay.

Initially, this was only required for the most expensive things, like hospitalization or surgery, and anyone from the doctor's office could call, give a decent reason for the procedure, and get an authorization.

Lately, however, plans often require pre-authorization for a large number of common things, like prescriptions or tests, and will not accept any but a small number of reasons to justify them. This means the doctor must pay additional employees to make these calls, and often get on the phone herself when the staff members are not able to give extensive enough information to get an approval.

It can become so burdensome that not all the doctor's patients can be accommodated, and the doctor then hesitates to order things that she otherwise would. At this point, competent doctors start leaving the plan or refusing new patients with that insurance if they possibly can, and you are stuck with whoever is left.



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©2000 Eileen K. Carpenter, MD