About 32 million Americans are enrolled in Medicare Advantage, a plan offered by private health insurers. Like original Medicare, these plans cover hospitalization, doctor visits, preventive tests, and medications.
Plans involve prior authorization, too. It’s also known as preauthorization, preapproval, or precertification. They all mean you need approval from your Medicare Advantage plan before getting certain services. Otherwise, your plan won’t pay for it. Prior authorization has been around for decades. It’s meant to keep your doctor from ordering tests or prescribing drugs that aren’t really needed. Otherwise, health care can get very expensive.
Some types of medical care that commonly require prior authorization include:
- Out-of-network care
- Non-emergency hospital care
- Specialist visits
- Certain prescription drugs
More than 35 million prior authorization requests were submitted to Medicare Advantage plans by patients in 2021. Most of these were approved.
How Do I Get Prior Authorization?
If your doctor decides you need a specific test, service, or medication that needs preauthorization, their office will put in a request for you. Doctors usually have a good sense of what does and doesn’t need prior authorization. But they won’t be up to date with every single Medicare Advantage plan. That’s why if your doctor thinks you need a certain service or drug, it’s a good idea to check with your insurance company to see if you need prior authorization.
If your prior authorization is approved, you may still have to pay part of the cost of the drug or service. You’ll have a fixed copay or coinsurance set by your Medicare Advantage plan, just as you would for any other test, treatment, or therapy.
It’s also important to note that prior authorizations are only in effect for a certain amount of time. Ask your doctor how often they’ll need to request prior authorization if the need is ongoing. Your Medicare Advantage plan may want proof from your doctor that the treatment helped you get better.
What Do I Do if My Request Is Denied?
The good news is most Medicare Advantage requests sail through. About 94% are approved. But others are denied fully or in part. For example, your doctor may request authorization for 10 physical therapy sessions, but only five are approved.
If your request is denied, it’s a good idea to appeal it. Research shows that about 80% of the time, Medicare Advantage insurance companies end up reversing the decision. Here’s how to do it:
Read the denial letter carefully. You’ll get a notice from your Medicare Advantage plan that explains why your prior authorization was denied. It should also have instructions on how to appeal the decision.
Ask for a copy of your medical file. It will contain information about your case. Your insurance plan may charge you for this.
Act quickly. You or your doctor must request an appeal within 60 days from the date you were denied coverage.
Provide all necessary information. This may include:
- Your name, address, and Medicare number
- The services that you want reconsidered and why
- The name of your doctor or any representative you’re hired to help you, like an attorney
- Any other information that you or your doctor thinks may help you with the appeal
Medicare Advantage plans have up to 30 calendar days to make their decision. If you or your doctor thinks this will endanger your health, ask for an expedited one. That means they have to respond to you with an answer within 72 hours.
Your doctor’s office can often help you fill out necessary forms. You can also ask your State Health Insurance Assistance Program for help filing the appeal. You can find your local office at https://www.shiphelp.org/.
Changes on the Horizon
You don’t need to worry about prior authorization if you’re in an emergency. Medicare Advantage plans must pay for emergency care at out-of-network hospitals at the same rate as in-network hospitals.
The federal government also passed new rules to make the preauthorization application process easier. Insurance companies must respond more quickly and provide more information if they deny coverage.
Show Sources
Photo Credit: E+/Getty Images
SOURCES:
Center for Medicare Advocacy: “Medicare Enrollment Numbers,” “Medicare Prior Authorization.”
Medicare.gov: “Understanding Medicare Advantage Plans,” “Appeals if You Have a Medicare Health Plan.”
Kaiser Family Foundation: “Examining Prior Authorization in Health Insurance,” “Over 35 Million Prior Authorization Requests Were Submitted to Medicare Advantage Plans in 2021.”
Patient Advocate Foundation: “What Does an Approved Pre-Authorization Mean?”
Centers for Medicare and Medicaid Services: “No Surprises: Understand Your Rights Against Surprise Medical Bills,” “2024 Medicare Advantage and Part D Final Rule (CMS-4201-F).”
