They’re the “Lobbyists” for Customers: Meet the Prior Authorization Team
This post was reviewed by our Director of Clinical Excellence and Oversight.
For people needing medical supplies for a life-threatening or serious condition, seeing the words “Prior Authorization Needed” on their prescription or physician’s order can be frustrating. In this situation, the patient is forced to gain approval for their healthcare need from their health insurance carrier before a specific service can be delivered. Getting this approval can be difficult for those without real knowledge or insight into how health plans work.
Getting Prior Authorization Approval Is a Skill
If getting Prior Authorization approvals sounds complicated, that’s because it is! Most Prior Authorization team members joined HCD with experience working with insurance companies or doctor’s offices. Their deep insight into how the system works and when additional information is needed to resolve a claim is critical to their success.
According to Patty, a member of the Prior Authorization team, the most difficult part of the job is getting the necessary documentation to support the need for a product that goes above what is commonly allowable by the insurance company. That’s one of the reasons that HCD’s practice of taking care of the paperwork really makes a big difference to customers. Having a team of professionals with contacts at the insurance company and the ability to easily reach doctors’ offices, as well as an understanding of what kind of documentation is likely to be needed, can significantly speed up the process of getting the approvals patients need.
The Prior Authorization team also understands the process from the healthcare professional’s viewpoint. “Doctor’s offices are busy places and getting Prior Authorization for a patient can be time-consuming,” says team member Celeste. “It’s our job to make it as easy as possible for the doctor’s office so they can focus on patient care.”
They Maximize Patient Benefits
If the insurance company denies a request, the Prior Authorization team will go the extra mile to provide the documentation that will help the request go through. The team works hard to show the patient’s need and will provide regular follow up to all parties involved until the request is finalized.
Another skill the Prior Authorization team brings to the table is their knowledge of what insurance companies will normally approve and what regulations are changing. When Covid hit, for example, there were changes to what insurance would pay for as well as qualifications for coverage, and additionally, each year regulations change that might impact insurance coverage benefits, and therefore patient orders.
Upcoming Changes to Medicare
Recently, Medicare announced there will be changes to what they will cover for a patient needing a CGM (Continuous Glucose Monitor). These changes will be effective on July 18, 2021. All the teams at HCD are trained and ready to integrate these new regulations into our systems. The Prior Authorization team will also kick into high gear to help customers maximize their coverage benefits with the new Medicare rules. This will ensure all appropriate Medicare customers can take advantage of getting a new CGM device to help manage their diabetes. As insurance regulations continue to evolve for the conditions HCD serves, including diabetes and CGM, incontinence, urology, wound care, and ostomy, you can count on all the teams at HCD to understand the documentation requirements and to be prepared to advocate on a patient’s behalf.
To experience our industry-leading customer care and have your medical supplies delivered right to your door, click the link on the bottom left of your screen. We accept Medicaid, Medicare, and many private and commercial insurance plans. The Prior Authorization team, and everyone at HCD, look forward to being your trusted partner in delivering the medical supplies you need to live with confidence and dignity.
Disclaimer:
Unless otherwise noted, the recommendations in this document were obtained from the sources indicated. Be advised that information contained herein is intended to serve as a useful reference for informational purposes only. HCD cannot be held responsible for the continued accuracy of or for any errors or omissions in the information. All trademarks and registered trademarks are the property of their respective owners.
