What is Prior Authorization
Prior authorization is a process used by insurance companies or third-party payers before they agree to cover prescribed medications or medical procedures. Insurance providers require prior authorization for reasons such as:
- Medical necessity
- Availability of a generic alternative
- Checking for drug interactions
A failed authorization can result in a requested service being denied, or an insurance company requiring the patient to go additional steps. The process can require a patient to try medication or a service preferred by the insurance provider, typically considered either more cost effective or safer, before the insurance company will cover a different service.
AUA Advocacy Efforts
When it comes to prior authorization issues, we’re working to support physician practices. Our advocacy efforts focus on reducing the burden that prior authorization causes practices and patients. In 2015, the AUA published a special white paper to support appropriate use of the Beers Criteria and its goal to improve effectiveness and safety of prescription practices for geriatric patients.
In October 2015, the AUA Board of Directors adopted a policy that reinforces our position that the Beers Criteria should not supersede clinical judgment or an individual patient’s values and needs, and that the list should not be used as a basis for coverage denials or prior authorization requirements. The AUA has also adopted the American Medical Association's Prior Authorization and Utilization Management Reform Principles.
Navigating Payor Forms
If you have additional concerns or questions, please email AUA at R&R@AUAnet.org.
Articles & News
Prior Authorization a Broad-Reaching, Significant Problem for Practices
AUA Policy & Advocacy Brief | May 3, 2016
Prior Authorization: How Practices Manage the Strain
AUA Policy & Advocacy Brief | May 17, 2016
Prior Authorization: What the AUA is Doing
AUA Policy & Advocacy Brief | June 7, 2016
Comments & Letters
Joint AMA comments to CMS on appropriate use criteria for radiology [pdf]
March 18, 2015