What is prior authorization and how can it reduce an employers UR costs?
A. “Prior authorization” is a an arrangement written into an UR plan that describes the specific conditions or circumstances under which a treating physician will be assured of ‘appropriate reimbursement’ for specific treatment, without submitting an RFA before, during or after the treatment. As long as that treatment fits the description of ‘prior authorization’ in the UR plan, the treating physician may treat and then submit the bill for payment. “Prior authorization” is made possible by the wording in regulations 9792.7(a)(5) and 9792.6(b). ‘Prior authorization’ is different from prospective review. ”Prospective review” (sometimes called pre-authorization) is the requirement or expectation that a physician will request authorization from the claims administrator or its URO before treating, which is very different from “prior authorization,” and which does not require the treating physician to submit a RFA at all. The section of the UR plan for “prior authorization” must describe th
