Independence Blue Cross removes select prior authorization requirements

By Faith Zantua, Co-Copy Editor

After a physician prescribes a scan to a patient, the patient often still has another step to worry about: prior authorization.

Health insurance company Independence Blue Cross and medical center Penn Medicine are piloting a program that eliminates prior authorization requirements for ultrasound, CT and PET scans. Health insurance companies currently require health care providers or patients to fill out prior authorization — also known as pre-approvals, pre-authorizations or pre-certifications — before receiving certain medical services, treatment plans, prescriptions drugs and medical equipment.

Prior authorization consists of forms that check if medical items are necessary and covered under the patient’s insurance plan. Prior authorization does not ensure that the plan will cover the cost. However, if not submitted, the provider may not pay for the cost even if the provider would have otherwise.

“If you go to a doctor, say ‘I have back pain’ and they send you to get an MRI, in order for the insurance (provider) to cover the MRI, the doctor calls the company. (You need a) pre-authorized MRI to get a copay,” Conestoga nurse Louise Cook said. “It’s a pain in the neck, but it ensures (that) the hospital is getting paid.”

The program applies to 1,280 Penn Medicine physicians employed at the Hospital of the University of Pennsylvania, Pennsylvania Hospital, Penn Presbyterian Medical Center and Chester County Hospital. Doctors must have a less than 2% coverage denial rate with IBX and a 12-month history of ordering scans. Meeting these requirements indicates that the physicians will most likely only order scans that are medically necessary without prior authorization.

The program aims to quicken the process of receiving care and decrease administrative duties. Although prior authorization is not required in emergencies and there are laws ensuring providers respond to prior authorizations by a certain amount of time, the process can still be inconvenient. Additionally, some patients find the process confusing.

“Sometimes it’s hard to know when (prior authorizations) are required,” said Tredyffrin Township resident Allison Montalvo, who has gone through prior authorization. “As long as your doctor or the doctor’s office is willing to do it for you, it’s not too big of a deal.”

According to IBX chief medical officer Rodrigo Cerdá, IBX plans to apply the program to health systems other than Penn Medicine if the program is successful. The program serves as a step to lessen the time and administrative burdens of general prior authorization requirements in health insurance.

“We (the Montalvo family) had a case last year (in which my daughter) broke her ankle. We needed pre-authorization to take her to a particular emergency room. In that case, it was really difficult because it was late in the day, (and) we had to call the insurance company,” Montalvo said. “So to not ever have to go through that process again would be nice.”

Faith Zantua can be reached at [email protected].