Navigating Prior Authorization: A Checkpoint on Your Healthcare Journey

Navigating Prior Authorization: A Checkpoint on Your Healthcare Journey. Just like planning a road trip, navigating a medical plan involves important checkpoints along the way. With employee benefits, one of the most important checkpoints is prior authorization, a step that helps ensure the care provided is safe, appropriate, and aligned with the plan’s benefits.

Before certain services move forward, a quick review helps ensure the care plan — whether it’s a medication, procedure, or treatment — is right for the patient. Like a planned stop on a road trip, this step helps keep the journey on track toward the best possible outcome.

In most cases, healthcare providers submit the request on the patient’s behalf, sharing clinical information to show that the service is medically necessary under the terms of their plan. Once reviewed, the insurance company approves, denies, or requests additional information.

Prior authorization does not apply to emergency or urgent care, such as a sudden appendicitis. In these situations coverage is reviewed afterward. Prior authorization is generally reserved for planned, non-emergency services, ensuring healthcare is both safe and appropriate, without slowing down critical care.

Why do medical plans require Prior Authorization?

Prior authorization might feel like an extra step, but it’s there for good reasons, helping balance quality outcomes with cost management. Here are a few ways prior authorization helps:

1. Ensure medical necessity: Plans cover care that is medically necessary. Prior authorization confirms a test, procedure, or treatment is appropriate and aligned with guidelines.
2. Promote safe and effective care: Some treatments carry higher risks or may not be the most effective first option. Prior authorization ensures safer or more conservative treatments are considered first.
3. Prevent unnecessary or duplicative services: Sometimes services have already been performed, or alternatives provide the same outcome. Prior authorization prevents unnecessary repetition.
4. Control healthcare costs: Reviewing high-cost services in advance helps manage expenses for both employers and employees while still supporting appropriate care.
5. Encourage cost-effective options: Where and how care is delivered matters. Prior authorization can help guide services toward settings or alternatives that are equally effective but more cost-efficient.

What types of services commonly require Prior Authorization?

While requirements can vary depending, prior authorization is often needed for:

• Advanced imaging (MRIs, CT scans, PET scans)
• Elective or non-emergency surgeries
• Certain prescription medications, especially specialty drugs
• Durable medical equipment, such as CPAP machines or wheelchairs
• Physical therapy beyond an initial number of visits
• Knowing where these checkpoints tend to exist can help avoid surprises.

What happens if Prior Authorization is missed?

Skipping a planned stop on a road trip or ignoring important road updates can be unsafe or lead you down a road that doubles your travel time. In healthcare, going ahead with a procedure or prescription without prior authorization can have serious consequences. For example, if a patient undergoes a procedure without approval, they could be responsible for the full cost if the service is denied.

Beyond the financial risk, skipping this step can also create safety concerns. A patient could take a medication that interacts dangerously with another drug they are already taking, or receive treatment for a condition that was not fully evaluated. Prior authorization provides a structured review to help prevent these kinds of issues.

At the same time, it can uncover opportunities to save money. For example, if a brand-name medication is prescribed, the insurance company may identify a generic or lower-cost alternative, helping reduce unnecessary expenses while still ensuring effective care.

Prior Authorization: Designed to support quality care

If you’re unsure whether a service requires prior authorization:

• Ask your provider’s office if they will handle it (most do).
• Review your plan summary or contact your insurance company.
• Reach out to your benefits advisor for guidance.

Prior authorization is not meant to delay or deny necessary care. It’s a process designed to ensure care is appropriate, safe, and aligned with your plan’s coverage. 

If you or your employees have questions about healthcare benefits or how prior authorization works under your plan, don’t hesitate to reach out. We’re always here to help!

Cost figures, coverage details, and plan design elements presented in this blog are for illustrative purposes only and do not reflect any specific insurance policy or provider. Actual costs will vary based on your organization’s health plan, the insurance carrier, provider contracts, and the specifics of each medical situation. Employers and employees should refer to their official plan documents or speak with their broker or benefits consultant for guidance if needed.