The problem with the prior-auth

The problem with the prior auth. 😖 ❌☑

I’ll try to make it easy using an analogy.

It has taken me a few years to understand the process and distill it down. It is an algorithm that is easy to sidestep.  

Insurers control the prior auth process and rules. But they only set the standard once a year ie. the plan document.The providers have no control over the process. BUT they had an unlimited(ish) amount of trials to figure out the algorithm.

Here is the comparison:(FYI - This is no laughing matter, anyone who has had a bill sent to them because the prior auth failure feels serious pain)

Because I am a learning parent, let’s say it’s a bedtime treat.  The parent is in control of the process.In order to get a bedtime treat, you need to do wall sits for 2 minutes and run around the house 4 times with proof.  

Child number one says “Dad, I want a treat.”

Dad: “Denied. No wall sits.”

Child: “I just did my wall sits.”

Dad: “Denied. Didn’t run around the house 4x.”

Child: “FINE, I just ran around the house 4x.”

Dad: “Denied. You forgot to have your brother approve of your 4x.”

Child: “Fine, he here is his note proving the 4x.”

Dad: “Ok, here you go.”

Well, the next time the child wants a treat, what do you think they will do?

Child: “Dad, I want a treat. I did my wall sits, and here is my brother’s note that I ran around the house 4x.”

Dad: “Ok…..well….. things look pretty good. Here you go.”

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For the rest of the year, it is isn't complicated for the child to get a treat.Most of the time, it encourages the right behavior.But for the grey areas, the providers know how to get things approved.  

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The grey areas are where the opportunity hides.