Insurance companies are the initiators of the prior authorization requirements. When a subscriber is relying on an outside payer source, to obtain payment, they must comply with the prior authorization process. A group, who makes up less than 1% of the population, determines how 10% of the nation’s gross national product will be spent. (Eisenberg, J.M. pg. 461)
Utilization Management Department assists with cost containment by managing health care costs. On a case by case review, requests are processed according to state and federal guidelines. Precertification and clinical appeals (focus on)
• Authorization processing delay: wrong ICD10/CPT coding, receiving clinical information, TAT (turn around time), member demographics. Use of Interqual or Milliman Guidelines.
• Denial Process: requires an MD review (only the Medical director can deny a request), follow up with an NOA (notice of Action letter) and timely appeal by the patient.
• Appeals: performed by a regulatory agency, the member who is receiving a denial, a plan representative (Medical Director/ UM manager)
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Studies were conducted on a local level for use of public marketing and tracking physician prescribing habits. A more recent review was established by WHO(World Health Organization), on drug utilization studies may include descriptive epidemiological approaches to the study of drug utilization, but also the assessment of how drug utilization relates to the effects of drug use, beneficial or adverse (Gama, H pg. 69). These reviews focused on one of the primary factor of the utilization process, which is medical necessity. A practitioner’s focus is on the patient, where as a drug manufacture is focused on