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Prior authorization requirements have been eased during the COVID-19 pandemic, but frustrations remain

April 27, 2020 / Jeff Lagasse, Associate Editor

The COVID-19 pandemic is changing the way healthcare does business — sometimes in temporary ways, sometimes in ways that may suggest permanent change when the crisis has passed.

Prior authorizations are one aspect of healthcare delivery that have been altered. Many insurers are waiving prior authorizations for diagnostic tests and covered services for COVID-19.

But frustrations still abound. Insurers increasingly require pre-approval, said David Shelton, CEO of patient advocacy group PatientMatters. This puts the onus on providers to obtain prior authorization for medical services — but that doesn’t necessarily guarantee the insurer will end up paying, and patients are often burdened with denied claims.

Specifically, Shelton addressed prior authorization for procedures or surgeries, not for medications. Traditionally, prior authorizations were only required for expensive, elective or new procedures. Patients are legally on the hook for bills if insurers refuse to pay for a preauthorized service.

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Chris J. Stewart

Chris currently serves as Chief Executive Officer of Surgio Health as well as COO at Ortho Spine Partners. Chris has close to 20 years of healthcare management experience with an infinity to improve healthcare delivery through the development and implementation of innovative solutions that solve real problems that result in improved efficiencies, reduction of unnecessary financial & clinical variation, and help drive better patient outcomes. Previously, Chris was assistant vice president and business unit leader for HPG/HCA. He has presented at numerous healthcare forums on topics that include disruptive innovation, physician engagement, shifting reimbursement models, cost per clinical episode and the future of supply chain delivery.

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