Is prior authorization required in UK?

[vocalEK]

I'm in the U.S. and in the health plans that are pay per service, prior authorization is required for any treatment that could be costly, e.g., surgery, radiation. This is much less a problem in the plans that are Health Maintenance Organizations (HMOs.) I am just curious how this works for my friends across the pond. The time required to obtain such authorization can be deadly, as this article points out. medpagetoday.com/radiology/...

[Julie2233]

This is my personal understanding of how it works in the uk. It's complicated but simple at the same time.

We have basically 2 systems, private and NHS (national health service which is state funded and free at point of delivery). Although in many respects the private mirrors what is allowed in the NHS. Most private companies will only pay for tests, treatment or drugs which are on the NICE approved list.

Access to treatment is generally quicker through private health care, that is where the advantage lies.

NICE (national institute of Care and Excellence) regulates what drugs can be prescribed through it's approved list. Every drug/treatment has to be shown to be cost effective as well as medically effective. If it's on the list the doctor is allowed to prescribe it without further authority. Private companies will generally authorise treatment the same day if it's used in the NHS and covered under the policy. In the NHS and occasionally in the private sector, the wait is often in getting an appointment with the doctor or for tests. Waiting list vary in different areas due to funding provision and priorities.

The next layer of complexity is the fact that the Nation health service isn't national. Each region receives different funding procapiter. It's up to each health authority to decide how to allocate this funding which affects waiting lists as well as treatment/drugs provision. It's known as the post code lottery. Just because a drug, test or treatment is on the approved list it doesn't automatically mean the health authority will fund it. An example of this is faslodex. Most private health companies will fund it because it's on the NICE approved list, but not all health authorities will authorise its prescription because of its cost.

Then with cancer treatment there is a further body which controls what is allowed. The Cancer Drug Fund species what drugs can be prescribed in what order. For example letrazole has to be prescribed before faslodex because basically letrazole is cheaper.

Cancer treatment is given priority over other treatments but there are still waiting lists, but generally once you've had the relevant tests and got to see the consultant, provided the treatment is allowed you don't have to wait for authorisation.

This is how I understand how the system here works, and probably more information than you wanted, hope it makes sense.

[WooWoogogo]

I have just recently been through treatment via private sources and a little bit on the NHS. In my case once I was diagnosed, I contacted my insurance company and they gave me a list of consultants that they have approved (NHS registered) in my area, then I pick one of my choice. They give you all their details so you can make a balanced assessment of them. Once I have decided which one to go with and which private hospital to attend, they book the appointment and give you a code to hand in. Thereafter, every bit of treatment needs me to call the insurance company to request a code. There has never been a problem on getting a authorisation code and all the operators are very clued up on cancer treatment. Often the appointments are made first, then I just follow it up with the authorisation code when I get there, but often the insurance company has already given the code to the hospital. They also do a thing called 'cash benefit' which is where you have certain treatment on the NHS and they will give you a certain amount of money per treatment. As far as I am aware these treatments are chemotherapy and radiotherapy. The private sector does work very closely with the NHS and some of the advice does overlap, but this isn't a problem, it just means more people are assessing your case.

I think that some policies allow you to pick which consultant you want regardless of whether they are NHS registered. However, there is no cap on my certain policy, which i am pleased about.

Hope this helps