Prior Authorization Module: How to Win the Game and Help Your Patients-Presentation 2 | Commercial Payer Policy and Prior Authorization

Video Transcription

Video Summary

This presentation by Dr. Joshua Rosenow of Northwestern University reviews commercial payer policies and prior authorization processes for neuromodulation therapies. It covers how insurers and third-party companies develop coverage policies—negative, positive, or silent—and emphasizes understanding specific criteria for coverage, such as documentation of medical necessity. Dr. Rosenow highlights the importance of detailed, tailored letters of medical necessity including prior treatments, psychological evaluations, and standardized scales to support prior authorization requests and successful appeals. Examples of coverage criteria from insurers like Aetna and Blue Cross Blue Shield demonstrate the variability in coverage and exclusions. The talk also explains the interconnected roles of third-party management companies influencing insurer policies, and stresses monitoring updates and aligning documentation with payer specifics. Recommendations include having a dedicated coordinator for authorization processes, leveraging manufacturer support for appeals, and maintaining thorough documentation to navigate the complex approval landscape and optimize patient access to neuromodulation therapies.

Keywords

neuromodulation therapies

prior authorization

commercial payer policies

medical necessity documentation

insurance coverage criteria

third-party management companies