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Understanding prior authorization

Employers know that providing health insurance benefits is important for workforce well-being. It helps employees access the care they need, when they need it. But many managed care practices that health insurers follow are misunderstood.

 

One key aspect of managed care is prior authorization. What does it mean for employer plans? How does it support the overall health of employees? Let’s go over it together.

What is prior authorization, and what are the steps?

 

Prior authorization is a process used by all health plans to promote quality care and manage health insurance coverage. It’s also called “precertification” or “preapproval.” Health insurers, like Aetna®, assess the medical need of services and treatments. This helps confirm that each person receives the best and most cost-effective health solution.

 

How prior authorization works

How prior authorization works

  1. Doctors file requests for their patients before they can provide certain medical services or medications.
  2. The health plan determines if the member’s benefits cover these services or medications.
  3. Aetna clinicians help uphold clinical quality and safety by reviewing the request using:
  • Clinical policy bulletins. Aetna clinicians develop these policies. They’re based on the latest peer-reviewed medical studies and expert guidance. They’re reviewed and updated regularly.
  • Regulations set by federal agencies or medical associations.
  • Industry-standard evidence-based guidelines.
  • Plan benefits.

A member goes to their doctor for new lower back pain

A member goes to their doctor for new lower back pain

The doctor may order an MRI (magnetic resource imaging). This advanced test helps doctors see organs and other structures inside the body for potential issues.

 

MRIs can help in some cases. But they can be inconvenient and costly, which can outweigh the benefits. In many cases, a provider may need to file a prior authorization request before the MRI is covered. Clinical teams then review the request to see if the MRI is safe and necessary for the patient.

Data shows that prior authorization works

Data shows that prior authorization works

For decades, health insurers have used prior authorization. It helps members avoid the costly risk of low-value care or even medical harm. Without prior authorization, members could pay for care they do not need. They could also receive a prescription for an expensive medicine when other high-quality options exist.

 

Data shows that prior authorization works (PDF)

 

Prior authorization also connects members to programs that help improve health and manage medical conditions. These programs include case and disease management, behavioral health programs and our National Medical Excellence Program®.

 

Learn about these programs

 

How does prior authorization help employers who use health plans to manage their employee populations?

 

Our customers contract with us to curb health care costs for both employers and members. Prior authorization assesses medical need. This helps health plans fulfill their responsibilities to employers and reduce the administrative and financial burden on providers and members.

 

Prior authorization can also improve workplace productivity.

 

  • It helps people better manage their health needs.

  • It helps people avoid missing work for emergency health situations.

  • During prior authorization, members may be referred to disease management programs. These programs can help prevent or manage chronic diseases and other health conditions. This helps control costs for employers and employees.

Here’s an example

A member has diabetes. Some diabetes testing supplies may require prior authorization. When an Aetna clinician reviews a prior authorization request for diabetes care, they can refer that member to a disease management program. The program helps the member understand their condition and follow their doctor's treatment plan.

 

Did you know?

Missed days of work due to diabetes cost $5.4 billion in 2022.*  Managing this disease is critical to members’ health and the health of total populations.

 

How is Aetna transforming prior authorization?

 

We know that providers and members can feel some frustration with prior authorization. That’s why we routinely adjust how we address evolving health care needs and treatments.

 

Over the last few years, we've:

 

  • Automated one out of four medical prior authorization approvals. Automated approvals are almost instant. We never automate denials based on medical necessity.
  • Removed requirements for over 1,000 providers through our special provider program.
  • Made sure our clinicians review prior authorizations that are based on medical necessity.

We’re committed to a better experience for everyone

 

Prior authorization is an integral part of managed care. Still, we keep working to streamline and improve our practices. We’re committed to working with employers to help employees live their healthiest lives, at work and beyond.

 

We’re committed to a better experience for everyone

 

Prior authorization is an integral part of managed care. Still, we keep working to streamline and improve our practices. We’re committed to working with employers to help employees live their healthiest lives, at work and beyond.

Legal notices

Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).

Health benefits and health insurance plans contain exclusions and limitations.

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