While many medical professionals like to give voice to their frustrations regarding prior authorizations (PAs)—they’re frustrating, time-consuming, and sometimes fruitless—it is not merely talk. According to an AMA survey, 91% of physicians feel that PAs can lead to negative impacts. Additionally, 82% believe that waiting for PAs can lead to patients abandoning care, and 34% have seen a PA lead to a serious adverse consequence for one of their patients.
When we reach a medical decision with our patients, it can be overturned by someone with no clinical experience and no degree in healthcare. If a PA is advanced to “a peer-to-peer,” we all know that peer is often not truly a peer reviewing the case. In fact, I recently had a podiatrist decide whether my patient needed a brain MRI. These “peers” are employed by the insurance company, with a goal to contain costs.
And yet, the PA game often leads to the opposite. In another survey, 24% of physicians reported that failure to obtain a PA led to a patient hospitalization. Delays in PAs also lead to diagnoses at later stages of disease, complications that could have been prevented with timely coverage, and other negative outcomes. You tell me which costs more.
It is estimated that 41 PAs are done per physician per week, equal to 2 business days every week per staff and physician. Imagine how much medical treatment we could provide in those 2 days. In 2019, this came at a price tag for physicians of $528 million. And it has only been increasing. In 2022, 79% of doctors reported an increase in PA requirements.
As medicine advances and we face more struggles with the COVID-19 pandemic and the aging population, we shouldn’t be forced to jump through hoops to get the medical care patients need. My own experience has shown me that pleas for services often fall on deaf ears. We need to end this useless coverage game. It is not good for patients, medical practices, or even the economy.
When dealing with PAs, it is often best to utilize the knowledge of someone with experience. Many nuances to getting approvals only come with that experience. When denials happen, it is important not to give up. Appeals can be filed, although that can be a lengthy process. When one course of action is not approved, it helps to switch plans, such as referring a patient to an orthopedist for a joint problem rather than fighting endlessly for an MRI to be approved. If a patient needs an urgent test, escalating the request up the chain of command (eg, asking to speak with the medical director) can help. If all else fails, every state has an insurance commissioner to whom a complaint can be filed.
While the process is frustrating, we need to remind ourselves that we are working for the best interests of the patient and that they are depending on us to give them the best medical care.
PWeekly