NOVEMBER 2017 ON HEALTH CONSUMER REPORTS 11 CR.ORG/HEALTH I f you’re covered by traditional Medi- care, you’ve only needed a doctor’s prescription to get expensive imag- ing tests such as MRIs, CAT scans, and nuclear imaging. But starting next year, that will change. Instead of relying solely on your doctor’s judgment to decide when you need imag- ing, he or she will need to go through an electronic portal to determine whether the test meets “appropriate use” guide- lines for your condition. Otherwise, Medicare may not cover it, and you’ll be billed. This requirement will be voluntary in 2018 but mandatory in 2019. If you have Medicare Advantage or a commercial insurance plan, it’s likely you’ve already gone through this pro- cess—and for more than imaging tests. Called prior authorization (PA), preautho- rization, and sometimes precertification, it means your insurer, not your doctor, decides whether a treatment, procedure, prescription drug, or medical equipment (such as an electronic wheelchair) is med- ically necessary and thus covered. But getting a PA isn’t always straight- forward. Whether you’ll be dealing with the new Medicare regulations or the rules of other insurers, here’s what to know: BE SURE IT DOESN’T SLIP THROUGH THE CRACKS If authorization is needed, your doctor or office staff should let you know and request it from your insurer. But if you don’t hear from your healthcare provider about the status of the request within five days, check back with the office. Sometimes insurers simply take their time arriving at a decision. A December 2016 survey of 1,000 doctors by the Ameri- can Medical Association (AMA) found that on average, 20 percent reported waiting three to five days for PA decisions from health plans, and 6 percent reported that it took more than five business days. Proactive Patient But your doctor’s office staff may also get backed up, forget to request a PA, or neglect to notify you that it has been at- tained. When it’s approved, be sure to ask for and write down the authorization number, because treatment facilities usu- ally require it. REQUIREMENTS DIFFER FROM INSURER TO INSURER Every insurance company has its own rules about which services require prior authorization. For example, Aetna, my carrier, requires it for inpatient stays (except hospice care), the use of an air ambulance, outpatient physical therapy, chiropractic treatment, pain manage- ment, and many other items, including a long list of medications. SOMETIMES IT’S NOT ENOUGH Getting prior authorization isn’t an absolute guarantee that your insurer will cover a service. In addition, the treatment must meet all of the conditions in the Summary Plan Description of your health plan’s policy. If your doctor is unsure whether a treatment will satisfy them, call your insurer. PA NUMBERS ARE TIME-LIMITED Your PA number won’t last forever. For example, the authorization number for commercial United Healthcare plans is valid only for 45 days. Ask your doctor what length of time the service has been authorized for—and jot it down—so you can avoid needless office visits and delays. NEW RULES MAY DELAY CARE Few doctors have the staff to handle the demands that PAs entail, and the new regulations will probably add to the burden. Indeed, eight out of 10 respon- dents in a 2017 Medical Economics “scorecard” of nearly 1,100 physicians reported that the process represented a significant challenge. And the 2016 AMA survey found that an average of 16.4 hours a week of physician and staff time was spent completing PA requests. Ninety percent of surveyed physicians reported that the process delayed patient access to necessary care. YOU CAN FIGHT A DENIAL If you receive a denial, ask your doctor why the service failed to meet appropriate- use guidelines. (Sometimes it may be that it’s not medically necessary.) But your insurer’s decision can be appealed. Usu- ally your doctor will even be able to request a peer-to-peer review so that he or she can explain the rationale for requesting the service to an insurance- company physician. ORLY AVITZUR, M.D., M.B.A., is Consumer Reports’ medical director. Board-certified in neurology, she is a fellow of the Ameri- can Academy of Neurology, a clinical instructor at the Yale University School of Medicine, and a medical consultant to the New York Rangers hockey team. A Medicare Change to Know About Starting soon, more consumers will need to get their insurer’s okay before imaging tests. This is not always a simple process. MRI scans may soon require a green light ahead of time in order to be covered by Medicare. Orly Avitzur, M.D., M.B.A. ILLUSTR ATION: EDMON DE HARO