patient care

Episode 2: The Prior Authorization Games: Where the Odds are Never in Your Favor

Greetings Readers.  I thought I would try something new and start somewhat of a series.  If you didn’t see my original post on prior authorizations, this link will take you right to it.

Last week I found myself on the phone, yet again arguing on behalf of a patient, to overturn the denial of the to pre-authorize a PET/CT scan.

The conversation was as usual, frustrating and, a waste of 15 minutes of my clinic time where I had to keep another patient waiting in the exam room.  (Because the insurance physician is only available during clinic hours, I cannot wait until after 5 PM when I am finished with my , but must sacrifice my schedule and keep other waiting in order to complete the phone call).  While in the end I obtained the approval for my patient, I was frustrated with the usual ridiculousness of the “peer-to-peer” discussion.

Here, is a summary of the conversation:

Insurance physician (IP):  “So, I see here this request is for a PET/CT scan?”

Me:  “Yes.   Let me tell you about the patient.  But first, I want you to know, I’ve been kept waiting on hold for 13 minutes, waiting to speak to you.”

IP:  “Uh, Ok.”

Me:  “Mrs. X. has a metastatic of unknown primary.  As part of our work-up to find the origin of the , I need for her to have a PET/CT scan.”

IP:  “So, what is the primary site of her cancer?”

Me:  (deep breath) “That’s what I’m telling you, we don’t know.  It is a cancer of unknown primary.  That’s why I am ordering the PET/CT scan — to try to help us find the site of the primary, in order to best recommend treatment options.”

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IP:  “Why can’t she have a CT scan?”

Me:  “She did have a CT scan.  It showed some possible thickening in the lower esophagus, and no other site of possible primary.  But she had a negative endoscopy.  The PET/CT scan will help us see if there is metabolic activity in the esophagus, or anywhere else.”

IP:  “Oh, she had a CT scan already?”

Me: (another deep breath, count to 10)  “Yes.”

IP:  silence

Me:  “I assure you, as a board certified oncologist, this is well within the standards of care of oncology.”

IP: (after a few more seconds of silence).  “Ok, I’ll give you an approval number…”

 

Do you have a good story on prior authorizations?  Reply in the comments field.

For resources on prior authorizations, see my original post , and here also are a few more I have found since my first posting:

Dear insurance doctor: You are not my peer

An insurance company denies a test. Here’s what physicians should do next.

Stay tuned, for episode 3.  (While I would for no more episodes, my practice experience unfortunately tells me there will be more…)

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Also published on Medium.

2 Comments

  1. Gerry Fosnot
    • jennifermd

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