Prior Authorization and Your Program – A Benefit. Not A Burden

Prior Authorization and Your Program – A Benefit. Not A Burden. While obtaining approval for medical treatments or medication can feel like a burden, imagine taking a medication that produces serious side effects when taken with another drug you are already on, or receiving treatment for a condition only to find out you were diagnosed incorrectly.

As an under-discussed area of healthcare, misdiagnosis and complications due to medication error are serious issues that could result in damaging consequences. According to a report by BMJ Quality and Safety, diagnostic errors affect 1 in 20 US adults a year. That is roughly 12 million Americans, and while some misdiagnoses are less detrimental, about 50% of the errors could be harmful. The “Big-Three,” known as vascular events, infections and cancers, account for most of the serious harms and should be the focus for developing solutions.

Help keep employees and their families informed – and protected.

Prior authorization is an essential part of a health plan. One that can help determine the medical necessity of treatments, tests and prescriptions. By taking this step, alternative options can be presented, sometimes reducing, or avoiding, adverse reactions or errors in medical decisions. For example, according to a Benefits Pro article, weight loss drugs Ozempic and Wegovy are facing several lawsuits from patients who accuse manufacturers of ignoring serious potential side effects. These side effects include gastrointestinal issues ranging from gastroparesis to gastric obstruction. Other GLP-1 drugs, such as Rybelsus and Mounjaro, are included in the lawsuits. The Health Care Blog shares that while drugs in this category have helped patients lose weight, “greater attention and resources must be devoted to treating the whole person and patiently evaluating the right and wrong candidates for GLP-1s.”

Power in the pause.

More time is needed to verify if the appropriate drug or treatment is being provided to patients. Prior authorization, along with the help of a trusted consultant, can provide that time. A step within your benefits to review how necessary a medication or medical treatment is, on an individual level, ensuring safety and optimizing outcomes.

Not only that, but a review of this kind could also produce cost-saving capabilities. For example, if a patient is prescribed a brand-name medication, an insurance company could determine if there is a generic or lower-cost alternative to the costly brand-name drug prescribed by the physician.

As with any business process, management is necessary. Prior authorization should not become a fixed protocol. Not all plan members fall into the same pre-set criteria. Having a consultant to answer employee questions and advocate for improvement provides a much-needed level of medical management that employees can trust. Whether that means establishing a patient is being prescribed the appropriate medication for their condition or ensuring a potentially addictive medication is being used appropriately.

Reach out today.

The goal for prior authorization is not meant to be a burden, but a process to help ensure employees receive the care they need, in the safest way.

If you have questions about prior authorization or medical management of your benefits, don’t hesitate to reach out. We’re here to talk with you.