The biggest misconceptions about prior authorization, according to payers

Common misconceptions about prior authorizations include how they are decided and their purpose, payer executives told Becker's.  

A common misconception providers have about prior authorization is that payers are "capricious and arbitrary," with authorization requirements, Darren Wethers, MD, chief medical officer of Atrio Health Plans, said. 

Some prior authorizations are proprietary to each payer, Dr. Wethers said, but most come from national criteria sets. 

"It would be helpful for providers to familiarize themselves with the coverage rules for the care they most commonly request authorization for in order to craft auth requests more likely to meet approval, and to do so for the plans that they most commonly do business with," Dr. Wethers said. 

Yvonne Collins, MD, chief medical officer of CountyCare in Chicago, said it is not the goal of prior authorization to delay or deny care. 

"As a payer, it is our responsibility to ensure our members have the most optimal care in the most effective level of care. We want to make sure the drugs/surgery/services given are based on evidence, effective for treatment and safe," Dr. Collins said. 

Neel Butala, MD, assistant professor of medicine-cardiology at the University of Colorado School of Medicine in Aurora and chief medical officer of HiLabs, said as a physician, his interactions with payers often center around prior authorizations. 

"However, through my work with AI solutions for payers, I have learned that this is only a small component of what payers do. If you look at where payers spend most of their time and energy, you find that it is spent on promoting the health of their members, health outcomes and coordinating care," Dr. Butala said. 

Read more executives' thoughts on the biggest misconceptions about payers here. 

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