Why Medicare Advantage Plans Require Medicare Prior Authorization Request
There are a lot of people enrolled in Medicare Part A and B who are confused about Medicare prior authorization requirements and denials.
This post will provide information on the process, the turnaround times, and more. Prior authorization in Medicare Advantage plans is no fun. Let’s explore how to deal with them, so beneficiaries’ access to Medicare services is not stopped.
Integrity Now Insurance Brokers wants to ensure you have all of the information so you can decide which Medicare plan is best for you.
What are Medicare Prior Authorization Requirements?
Medicare Prior Authorization requires that a healthcare provider obtains approval from Medicare to provide a given service. For example, if a doctor wants to perform knee surgery on one of their patients, they must first get approval from the Medicare Beneficiaries Medicare Advantage plan.
Home health services may also require prior authorization before a Medicare Advantage plan will cover expenses related to home health coverage. If prior approval is not obtained, the private insurance company will produce a claims denial letter to the Medicare beneficiary and home health agencies who provided the service.
Original Medicare with a Medicare Supplement Plan G does not traditionally use prior authorizations for Original Medicare enrollees. This removes the consequences of not obtaining prior authorization from the government, which can equal cost savings to the Medicare beneficiary.
Does Original Medicare Require Prior Authorizations?
Original Medicare does not require prior authorization for most services. However, some services, such as durable medical equipment, may require prior authorization.
Do Medicare Supplement Plans Require Prior Authorizations?
Medicare Supplement plans are considered a secondary insurance policy. Original Medicare is the Medicare Beneficiaries’ primary health insurance plan.
Why Do Medicare Advantage Plans Require Prior Authorizations?
Medicare Beneficiaries who enroll in Medicare Advantage plans to give up their rights earned through Original Medicare. They transfer their decision-making power from their treating physician to the insurance company to decide their health benefits.
Medicare Advantage plans have the authority to require prior authorizations to provide certain services.
There is a new movement to limit Medicare Advantage plans authority to require prior authorizations. This is because the HHS Office of the Inspector General recently found that Medicare Advantage plans you deny care – inappropriately – at a high rate.
Members of Congress are concerned about using prior authorizations and asked CMS to collect data on the scope of prior authorization practices.
The process for obtaining prior authorizations can take up to six months. The OIG has found that obtaining prior authorizations is often flawed.
As of this writing, Medicare Advantage plans have no restriction on enforcing prior authorizations. Congress is seeking to continue to allow prior authorization for Medicare Advantage plans; however, they may attempt to reduce the number of allowable procedures.
What are the Top 10 Types of Services that Require Medicare Prior Authorization?
Depending on your Medicare Advantage plans, most medical procedures require Medicare prior authorization unless it is for a primary care visit. Examples of medical procedures that may require prior authorization from Medicare include the following:
- Specialist visits
- Therapeutic drugs (cancer treatment drugs may require step therapy with Medicare Advantage plans)
- Mental health services
- Radiology services (MRI, CT Scans)
- Out-of-network doctors visits
- Certain laboratory test
- Durable medical equipment (DME)
- Chiropractors visit
- Dialysis treatments
How Long Does it Take to Get Medicare Prior Authorization?
Prior authorizations are different for each Medicare Advantage insurance company. The range can be a week to several months, assuming your medical procedure or a stay in a medical facility is approved by the private insurance company.
What Factors Dan Delay or Deny my Medicare Prior Authorization Request?
1. Previous medical history
Medicare prior authorization is a process used to check whether a person’s healthcare needs would require more than the standard benefits offered by Medicare. Factors that can delay or deny a request for Medicare prior authorization include the complexity of the request, lack of documentation, and appeals processes.
Comorbidities are conditions that occur alongside another medical condition. They can delay or deny Medicare prior authorization requests.
3. Drug regimen or treatment history
Factors that may delay or deny a prior authorization request include: if the drug is not appropriate for the individual member, if applicable Medicare guidance does not support the use of the drug, if the FDA-approved labeling does not recommend the dosage, and if the terms of their benefit plan do not allow for coverage of the drug.
The Medicare Advantage company may also implement step therapy and change the requested drug to a lower costs medication.
4. New or changed medical symptoms
The insurance company must conduct an internal review if the Medicare Beneficiary has a new or change in a medical symptom.
The following are the reasons for the delays:
- Lack of information: If a provider or supplier does not submit enough information with a request, it can be delayed or denied. For example, the request may be delayed or denied if a provider requests authorization for a new medication but does not include the patient’s medical history or other relevant information.
- Incomplete documentation: If a provider or supplier submits incomplete documentation with a request, it can be delayed or denied. For example, if a provider requests authorization for a new medication but does not include the patient’s prescription, the request may be delayed or denied.
- Prior authorization requirements: If a service requires prior authorization and the member has not met all the requirements, the request may be delayed or denied. For example, if a member has not tried an alternative treatment first (such as step therapy), their demand for prior authorization may be delayed or denied.
- Time limits: Medicare regulations state that providers and suppliers must submit requests for prior authorization within specific time frames. If they do not, the request may be delayed or denied. For example, if a provider submits a request for prior authorization more than 30 days after the date of service, the request may be delayed or denied.
- Duplicate requests: If a provider or supplier submits a request for prior authorization that is identical to a previous request, it may be delayed or denied. For example, if a provider resubmits a request for prior authorization that was already denied, the request may be delayed or denied.
As the medical provider is not in control of your treatment plan under a Medicare Advantage plan, they need to obtain prior authorization from the insurance company that sends the request to their medical team for approval.
5. Clinical judgment by the doctor or specialist
If a doctor or specialist denies a Medicare prior authorization request and will not submit it to the insurance company for approval, it will delay or deny coverage. While these instances are rare, it happens when the doctor feels your symptoms do not require the care you seek.
Does Medicare Part D Prescription Drug Coverage Require Prior Authorizations?
Medicare Advantage and Part D plans may require prior authorization for some prescription medications. Medicare Beneficiaries should contact their plan to confirm if prior authorization is needed.
Your health insurance coverage may want beneficiaries to use a less expensive drug before prescribing the requested pain management medication. It is best to review your Part D formulary before you sign up for a Medicare plan so you will not need to request an exception.
How can I appeal a decision about my Medicare prior authorization request denial?
Step 1: Check if you can appeal the decision
The provider and Medicare Beneficiary can appeal if the claim is denied. All appeal rights are then available if they are filled within the appropriate timeline.
Step 2: Get more information about the decision
If you have been denied a Medicare prior authorization request, review the denial letter to see why they made this decision. Your provider can contact the plan to get an exception approved. If approved, the plan will pay without prior authorization.
Step 3: Submit a written appeal
To submit a written appeal, the provider should select the appropriate request type and allow 10 business days for a decision. If the provider needs a decision faster, they can choose the “expedited” request type.
The provider must include the most recent UTN with each written appeal submission. Claims subject to PA requirements under the hospital OPD program follow all current appeals procedures.
To submit a written appeal, providers should follow the instructions from the CMS Medicare Claims Processing Manual and include information such as the date of service, diagnosis, and treatment involved in their appeal.
Step 4: Schedule a meeting with the reviewer
If you disagree with a decision about your Medicare prior authorization request, you can appeal the decision. To appeal the decision, you must contact the reviewer who made the decision. You can find the reviewer’s contact information in the decision letter.
Remember to always be polite and respectful in your conversation with the reviewer. They may inform you that your doctor did satisfy the documentation requirements and what is still needed.
Step 5: Have your say at a fair hearing
The fair hearing process allows you to appeal a decision about your Medicare prior authorization request.
The hearing will be conducted by an impartial panel reviewing the evidence and deciding. If you are still dissatisfied with the outcome, you may file an appeal with the Centers for Medicare and Medicaid Services.
Step 6: Get help from Medicare
If you are appealing a decision about your Medicare prior authorization request, you may need to contact Medicare directly versus talking with the private insurance company. Sometimes just contacting your plan is insufficient to obtain your medically necessary care.
Medicare may be able to provide additional resources in your fight for Medicare coverage and reverse the plan’s decision.
The prior authorization program enforced by Medicare Advantage plans leaves seniors susceptible to being taken advantage of. It’s also time-consuming for doctors to submit prior authorizations and follow up on any missing documents so your treatment can be approved and your bill will be covered by insurance.
Requiring prior approval for basic procedures should not be allowed. The prior authorization process is broken and needs to be fixed.
What is the Medicare Prior Authorization Guide?
The Medicare Prior Authorization Guide is a document that explains the process and requirements for getting prior authorization for certain Medicare services. It includes information on what services require prior authorization, how to request prior authorization, and what documentation is needed.
The guide also provides an overview of the Medicare appeals process.
What are the steps in the Medicare authorization process?
There are four steps in the Medicare authorization process:
- The first step is to determine if Medicare will cover the proposed treatment. To do this, the treating physician must submit a request for pre-authorization to Medicare.
- Once Medicare has received the request, a team of reviewers will assess whether or not the treatment is medically necessary.
- If the reviewers determine that the treatment is medically necessary, they will authorize coverage and send a confirmation letter to the treating physician.
- If the reviewers determine that the treatment is not medically necessary, they will deny coverage and send a written explanation of their decision to the treating physician.
What is the turnaround time for Medicare authorization?
The turnaround time for Medicare authorization can vary depending on the specific situation. Generally speaking, getting an answer from Medicare can take a few days to a few weeks. In some cases, it may even take longer.
What are the delays in the Medicare authorization process?
There are several delays in the Medicare authorization process. These can include delays in getting pre-authorization for services, getting authorization for services that Medicare does not cover, and obtaining authorization for services that Medicare does not cover.
Does Medicare require prior authorization for inpatient surgery?
Yes, Medicare Advantage plans to require prior authorization for inpatient surgery. Original Medicare with a Medigap Plan G does not require prior authorizations.
Does Medicare require prior authorization for outpatient surgery?
No, Original Medicare does not require prior authorization for outpatient surgery. However, your Medicare Advantage plan will require you to get prior authorization before they will pay for certain services or supplies.
What is the point of prior authorization?
Prior authorization is a process that private insurance companies use to decide whether they will cover a specific medication or medical procedure. The point of prior authorization is to make sure that patients receive the most appropriate and cost-effective care possible.
Does Medicare require prior authorization for physical therapy?
No, Traditional Medicare does not require prior authorization for physical therapy. However, some Medicare Advantage plans may require it. Check with your plan provider to see if prior authorization is required.
Does Medicare require prior authorization for MRI?
Medicare Beneficiaries enrolled in a Medicare Advantage plan will be required to obtain prior authorization for an MRI to comply with Medicare Advantage plan requirements. Traditional Medicare with a Medigap plan does not require prior approval, which can improve the quality of care.
Does Medicare require prior authorization for echocardiograms?
No, Original Medicare does not require prior authorization for echocardiograms. However, some private insurance companies may require it. If you have private insurance through a Medicare Advantage plan, you should check with your insurance company to see if they require prior authorization for this test.
Does Medicare require prior authorization for specialists?
Traditional Medicare will not require prior authorization for Medicare Beneficiaries to see a specialist. You can see any specialist that accepts Medicare without getting a referral from your primary care doctor.
Medicare Beneficiaries enrolled in a Medicare Advantage HMO plan, are required to obtain a referral prior to rendering services from a specialist. If a Beneficiary goes directly to a specialist without a referral this could result in specific items and services obtained not being covered by your Medicare Advantage plan.
How do I obtain a Medicare Part B medication prior authorization form?
Medicare Part B drugs are typically cancer-fighting medication and are administered at a medical facility. Once you receive your prior authorization to see your cancer doctor, prior authorization is also required for the medication for Medicare patients.
Medicare Advantage plans will implement step therapy limiting the use of certain drugs that are more costly. With Traditional Medicare combined with a Medicare Supplement insurance policy, your doctor only needs to show the drug is a medical necessity to save your life.
A few ways exist to obtain a Medicare Part B medication prior authorization form. The first way is to contact the Medicare plan directly and request the form. The second way is to download the form from the Centers for Medicare and Medicaid Services website. The third way is to ask the prescribing doctor for the form.
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