Care can’t always wait. When members are navigating serious medical conditions, a delay of days can yield worse outcomes, and a delay of weeks or months can be a death sentence. Although pre-authorization requirements are often seen as a barrier to timely care – and they can be depending on how they’re administered – ICM’s pre-authorization services help ensure that members receive appropriate, evidence-backed care when they need it.
The Role of Pre-Authorization
If health plans are to stay financially healthy, they cannot pay every claim without consideration for the medical necessity and cost-effectiveness of the care in question. Furthermore, if plans wait until after care is provided to determine coverage eligibility, members may end up responsible for thousands of dollars in uncovered medical bills, possibly when more cost-effective and clinically proven options were available. No one wants to go into medical debt for unnecessary care.
In addition to verifying that requests are standard of care, pre-authorizations can also help members and providers to understand coverage in advance so members can receive care with a full understanding of potential out-of-pocket costs. When you consider that 37% of adults with health insurance say they have avoided needed healthcare due to costs, according to a KFF poll, it’s clear that addressing financial concerns is crucial. When members are worried about costs, they may not receive any care at all, and that can be detrimental to long-term outcomes.
Pre-authorization protects both members and plans from unnecessary costs, but this does not mean it’s beyond reproach. A system is only as strong as its processes. If pre-authorization decisions are made without medical evidence, or if the process takes too long, member care can suffer.
ICM takes a balanced and evidence-based approach to pre-authorization. The plan determines when pre-authorization is required, and when it is, we quickly review requests to assess relevant facts, such as medical necessity and network participation. Our goal is not to deny care; it’s to ensure that care is appropriate and evidence based. We also understand the human side of the process, and our approach is compassionate and objective.
Case in Point: Treatment Approval When Every Day Counts
UFCM Local 555, a labor union representing workers in a variety of industries in the Oregon, Idaho, and Southwest Washington, uses ICM’s services to ensure that members receive the care to which they are entitled.
Dan Clay, the President of Local 555 and a trustee of the employee health trust, recalls a case involving a member with a brain tumor. the treatment the doctor recommended was originally denied, and although the member had a right to appeal the decision, the process could take 60 to 90 days. The member did not have this kind of time; the brain tumor required urgent treatment, and a months-long delay amounted to a death sentence.
Dan contacted ICM for assistance. ICM immediately researched the case and determined that the doctor’s recommendation was medically necessary. ICM’s clinically backed recommendation was enough to secure fast approval with the carrier, and the member had the surgery she needed within a week. It was a remarkable success story!
Case in Point: Assessing the Best Care for the Best Outcome
It’s no secret that healthcare is expensive in the U.S. Sometimes members can save hundreds or even thousands of dollars by switching to a less expensive facility while receiving the same quality of care. If plans can steer members toward these less expensive options, everyone can benefit.
However, immediate cost savings are not always worthwhile in the long run. ICM takes a balanced and holistic approach to pre-authorization recommendations. Sometimes, spending extra money now is necessary to support positive outcomes and avoid even greater costs down the road.
This was the case when one particular member needed care for a rare form of cancer. One facility that provided treatment options was known to be costly, so the plan would normally not approve it, but data showed that the facility also had better outcomes for the member’s diagnosis. It would cost $15,000 more – but the clinical excellence justified the cost.
ICM quickly assessed the situation and advocated for the plan to make an exception in this case, and thanks to this input, the member received the timely, effective and clinically sound treatment she needed.
Taking A Balanced Approach
ICM’s approach to pre-authorization shows that it is possible to balance the human-side of medicine with the financial realities of the U.S. healthcare system, and processes can move swiftly to avoid delays in urgent care.