Insights into the Prior Authorization Process
Insurance companies (IC) utilize the prior authorization (PA) process to ensure that a given service meets their contractual terms with their customer (your patient). The process, done via an online portal, email, or by call, seeks additional information from the provider (you) to determine the medical necessity (or eligibility) of a given procedure being recommended for their client (your patient).
Any IC may require a PA for specific events. The events and approval requirements vary between companies. A PA may be necessary for surgeries, procedures (such as X-rays, scans, labs, etc.), consults with other providers, medications, or treatment plans.
As the name implies, prior authorization must be completed before treating the patient. Failure to do so will often result in a denial of payment to the provider and perhaps financial implications for the provider or patient.
Insurance carriers are an integral component of the US healthcare reimbursement triad, which consists of patients, providers, and ICs.
The IC has two inherent business goals: first, to collect money from premiums, and second, to pay claims according to their contractual obligations with their customer (your patient). If they deny a PA, the insurance company pays less in claims and makes more money.
Here are the basic steps:
1. Verify the patient’s insurance coverage.
2. Check the IC PA procedure listing to determine if a PA is required.
3. Determine the IC required documentation and submission method if a PA is needed. At a minimum, IC will often require the most recent office note and may indicate other supporting documentation.
4. The IC often defines an expected timeframe for submission and responses. Make sure to work within those time frames, or your PA may be denied.
5. As you do this process, you will find patterns of what documentation the IC PA process is looking for approval (it is often not clearly defined by the IC; trial and error are required on your part). Vendors of products or services you are obtaining the PA for may be good resources to determine what is necessary to approve the IC PA process.
For osteoporosis and bone health providers (OBH):
Special note regarding office notes, especially when requests are being made for PA, make sure documentation includes:
1. History (medical, fracture, family, surgical)
2. If a fracture is involved, what is the mechanism, and what was fractured?
3. Test results (labs, BMD/T-Score, TBS, etc)
4. Risk Scores when appropriate (FRAX, Garvan, etc)
5. Diagnosis (often multiple)
6. What is your treatment plan? Be specific as to procedures or treatments.
7. Expected duration of treatment
8. Are there studies, guidelines, or position statements to support your request, and from whom?
Insurance carriers are critical, but your relationship with the IC will often feel more adversarial than acrimonious. They will not make assumptions or connect the dots to follow your treatment plan or logic. It becomes the classic “if it’s not written, it doesn’t exist.”
As you go through this process, remember that you are your patients ‘advocate on their pathway to high-quality care. The IC is most likely not as interested in your patient’s outcome as you are.
Rethinking Osteoporosis Bone Health (OBH) Care: A Path to 21st-Century Success
Over the past 30 years, significant efforts have been dedicated to educating providers and setting goals in U.S. osteoporosis bone health (OBH) care. Despite these efforts, the system has become ossified, often hindering progress at the patient level. To achieve meaningful advancements, we must shift from a medical practice model to a comprehensive healthcare business model.
A strategic vision and goal-setting are crucial for transitioning the current fee-for-service model to one centered on value-based care. This transition must prioritize measurable outcomes, such as reducing fractures and lowering societal healthcare costs. The Five Pillars of Success, championed by the American Society of Osteoporosis Providers (ASOP), provides a framework to shift the focus from simply measuring T-scores to assessing fracture and complication risks—and reducing those risks in a sustainable, repeatable way.
The Five Pillars of Success
1. Patient Identification
The system's foundation is identifying patients for OBH care. This involves leveraging tools such as population health analytics, electronic health record (EHR) queries, AI-driven radiographic fracture risk assessments, and screening programs for primary and secondary osteoporosis. Specific patient populations, such as preoperative orthopedic patients (e.g., spine and total joint patients), present key opportunities for intervention.
Each identification method requires unique processes but ultimately converges on a common goal: engaging patients in OBH care. A significant challenge remains the shortage of providers equipped to care for the identified patients.
2. Enterprise and Professional Education
Education in OBH has not kept pace with advances in the field. Providers often receive minimal training based on outdated knowledge from decades ago, leading to unrealistic expectations and program failures. For example, healthcare executives may struggle to predict the return on investment for an OBH program, understand revenue streams, or assess staffing needs.
ASOP has developed an enterprise-wide return-on-investment (ROI) calculator to address these gaps. This tool helps organizations evaluate patient volumes, revenue potential, staffing requirements, and fracture reduction outcomes. Certification-level training for basic and advanced healthcare providers is also under development, offering standardized education that ensures sustainability and scalability for OBH care.
3. Patient Engagement
Engaging patients is critical to OBH's success and represents the midpoint of their care journey. Providers must be skilled and confident in OBH, capable of interpreting tests, assessing risks, and formulating treatment plans. They should clearly communicate the importance of risk reduction for enhancing quality of life, just as they would for other chronic conditions.
Providers act as quality control checkpoints, ensuring accuracy in OBH screening protocols, bone density testing, lab assessments, and treatment plans. Their expertise should enable them to guide the engagement process effectively, though administrative tasks like insurance authorizations are handled by support staff.
4. Patient and Staff Retention
Retaining both patients and staff is vital for a successful OBH program. Patients who feel well cared for are more likely to stay engaged long-term, while providers who feel valued and supported are more likely to remain in their roles. Stability in staffing leads to better patient satisfaction, ultimately enhancing retention rates for both groups.
Strategic planning for staffing ensures the enterprise can meet future OBH demands, contributing to operational success and improved patient outcomes.
5. Enterprise Success Matrix
An effective OBH program requires a clear enterprise success matrix to guide growth and sustainability. This includes modeling financial success, setting realistic goals, and optimizing resource utilization.
The positive impacts of OBH extend across multiple stakeholders:
- Patients experience improved quality of life through reduced fracture risk.
- Healthcare providers benefit from professional recognition, standardized training, and access to better resources.
- Enterprises achieve value-based care goals, generate revenue, and improve public and patient relations.
- Society realizes cost savings from reduced fractures and surgical risks.
A New Future for Osteoporosis Bone Health
By adopting the Five Pillars of Success, OBH care can evolve to effectively address fracture risk and prevention. This roadmap integrates professional organizations, governmental and private resources, and innovative technologies to achieve shared goals. The goal is to move from asking, "What is your T-score?" to "What is your fracture/complication risk, and how can we reduce it?" in a sustainable and impactful way. Together, we can transform osteoporosis care for a better future.