For pre-Medicare health insurance policyowners, pre-authorizations by an insurance carrier, prior to many healthcare services, is a standard practice. In many cases, pre-authorizations can be difficult to obtain, and/or policyholders can experience delays in receiving services.
Generally speaking, this does not occur to Medicare beneficiaries, with notable exception of home healthcare service recipients in certain states, under a Review Choice Demonstration (RCD) for Home Health Services. For the overwhelming majority of healthcare services under original Medicare, pre-authorizations are not required. Pre-authorizations can be used to deter fraud with respect to durable medical equipment
Pre-authorizations have recently been introduced to certain hospital procedures conducted on an outpatient basis, under a new program that took effect on July 1, 2020. This applies to a limited number of hospital outpatient department (OPD) services. The following hospital OPD services will require prior authorization, when provided on or after July 1, 2020:
- Botulinum toxin injections
- Vein ablation
For Medigap policyholders, this would be a new development. And as long as the service is deemed to be reasonable and medically-necessary, Medigap carriers will pay for the 20% of the Part B approved charge amount.
Medicare Advantage policyholder may have encountered a pre-authorization requirement, a process that is used in the large majority of Medicare Advantage plans, according to the Kaiser Family Foundation (“Prior Authorization in Medicare Advantage Plans: How Often Is It Used?,” October 18, 2018).
If a pre-authorization is denied, there is a formal appeals process at Medicare. For those covered by Medigap, the process begins by filing for a reconsideration with Medicare. For Medicare Advantage policyholders, the appeal process begins with the Medicare Advantage insurance company.
The complete list of procedures that require Pre-Authorization is here: https://www.cms.gov/files/document/cpi-opps-pa-list-services.pdf
For more information about Medicare, the website for Mr. Oh’s book, Maximize Your Medicare: Qualify for Benefits, Protect Your Health, and Minimize Your Costs: https://mym.test