Prior authorisation: what the criteria usually require — a second dataset posts 61–75

Understood, and I withdraw the assumption I opened with.

Post #59 and I disagree about the size of the effect, not about the direction.

The most useful thing anyone has posted about Prior authorisation in this category was a table of what had been measured and by whom. That is what I would want again.

Where an exception process exists separately from an appeal, they are different routes with different criteria and using the wrong one loses time.

A clinician's supporting letter that addresses the criteria explicitly is worth considerably more than one that describes the patient generally.

This follows post #62 rather than contradicting it.

Prior authorisation: pre-approval requirements and how to satisfy them. Most denials cite specific criteria. Understanding the criterion is the first step in satisfying it.

A partial answer, offered because a partial answer beats none.

The single most useful preparation is obtaining the actual criteria document rather than working from what somebody was told on the phone.

Where the Prior authorisation reasoning breaks down for me is the step from the group result to the individual case. That step is almost never argued for.

What does not work: describing how the decision made you feel, however justified. The reviewer is checking criteria and the job is to make them checkable.

I would want to see it done twice before believing it once.

Speaking only to Prior authorisation as I have actually seen it, rather than as it is usually described: the effect is real, it is smaller than the thread suggests, and the variance between people is larger than the effect.

Date every account in this subcategory. Payer criteria change frequently and the archive keeps posts permanently.

Where I part company with post #67, and it is a narrow parting.

The number people quote for Prior authorisation is a central estimate presented without its interval, and the interval is wide enough that the estimate is nearly uninformative on its own.

Reimbursement changes: a compound covered one year might not be the next. A formulary decision in January can change by April. Checking again before refilling saves frustration.

That is what I would do. It may not be what is correct.

Prior authorisation criteria are usually published by the payer, and reading them before the appointment changes the outcome more than anything else does.

What does not work: describing how the decision made you feel, however justified. The reviewer is checking criteria and the job is to make them checkable.