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

I am not the first physician blogger to write about the difficulties of prior authorizations, denials, and appeals, but recent occurrences in my own practice have been so convoluted that I feel they must be shared.

The nonsensical denials would almost cause one to laugh, if not for the reality that each denial represents potential delay in care for the patient and redundant work for the physician — work that expands exponentially from the initial time taken to submit a carefully-worded request (in the futile that one might receive an approval on the first try).  The incredulous laughter at the absurdity of the denials turns quickly to lamentation as my inbox fills each week with more and more denials of for reimbursement, which must be appealed.

Case #1.

I requested an MRI of the brain for a patient with a history of malignancy, now with new concerning neurological symptoms.  The approved the MRI, but only WITHOUT gadolinium contrast.  I had requested the MRI to be done WITH gadolinium contrast.  Some nameless, faceless, person at the , who has never met my patient, and I am certain does not have a , dictated what kind of MRI that I could order.  It seemed they were willing to concede the patient needed the MRI, but they wouldn’t approve it the way I, the physician, a medical oncologist, had ordered it.  This degree of attempt at micromanagement of my medical care of my patient was jaw-dropping.

The letter indicated I could appeal the decision in writing.  I was so upset at the ridiculous nature of the denial that I wrote a more forceful letter than is my typical approach.  Here is an excerpt:

… I have ordered an MRI of the brain WITH contrast in order to evaluate the brain and meninges for any evidence of malignant involvement of the CNS.  This is according to current standards of practice in oncology.  For reasons that are entirely unclear and inexplicable to me, your company has approved only an MRI WITHOUT contrast.  Without the use of contrast, the radiologist cannot adequately evaluate the brain and meninges.  Please approve the MRI of brain WITH contrast ASAP so that we can properly take care of our patient.

Less than 24 hours after I faxed the appeal letter, a response letter of approval was on my desk; for MRI — WITH contrast.

While I was grateful for the patient’s sake that the approval turned around so quickly (not always the case — sometimes these appeals drag on for weeks), I couldn’t help but reflect on the situation, that what it really comes down to is a deep lack of .  The insurance company does not that I, as a physician board-certified in my specialty, know the best test to order for my patient.  Why is that?

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Taking it one step further, if insurance companies can dictate what kinds of tests that we, as physicians, can order, why do we have a board-certification process to begin with?

I re-certified for both medical oncology and hematology within the past 1 year.  It was a good opportunity to review changes in practice and provided the reassurance that I was up-to-date in my fields of specialty, and I have the certificates again to prove it (at least for the next 10 years).  It was also a lot of work, expense, and time away from my practice.  And for what?  What good is being board certified in one’s specialty if someone without a medical degree is deciding what kind of tests will be reimbursed by insurance?  If insurance companies trusted the board certification system (for medical specialties, the ABIM — American Board of Internal Medicine), they wouldn’t second-guess our every radiology order, and make us submit “proof” of why we are ordering them on our .  Isn’t the “proof” in our medical degree, and our board certification?  The only conclusion that can be drawn is that insurance companies do not trust that being licensed and board-certified in one’s specialty means a physician knows what s/he is doing.

The irony is, I try to put the information I know they will ask for in the original order and the clinic note that accompanies the order.  I don’t think anyone with any medical knowledge reads it.  The result being that I have to double my work and write a letter with the same information and submit an appeal to finally reach someone, we presume, with some medical knowledge, to “authorize” the test that the board-certified physician has already determined to be indicated.  Like every physician I know, I am not given extra time in my clinic day to take care of these administrative tasks, so I am often doing them after clinic hours, on my “own” time.

Case #2

A patient with an upper extremity DVT (deep venous thrombosis) associated with an implanted portacath had completed a course of definitive chemotherapy, and we thus wanted to allow the surgeon to remove the portacath.  I recommended a repeat ultrasound to make sure the anticoagulation (blood thinner) treatment had been effective against the blood clot, before the surgeon removed the portacath.

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We received a notification of denial of prior authorization.  The reason:  this insurance company only authorizes repeat ultrasounds for lower extremity DVT for ONLY the following 2 criteria:  (1) one week after diagnosis of the DVT, or (2) up to three times in the first 2 weeks if a DVT in the calf is not being treated.

My immediate thoughts on this as a board-certified hematologist were:

  • These criteria make no clinical sense for any DVT patient
  • They don’t even apply to my patient as the DVT is not even in his calf.

So again, I wrote the obligatory appeal letter.  I explained in great detail where the blood clot was, what a portacath is, and the potential dangers of the surgeon removing the portacath if there was still a large blood clot at the tip of it.  Based on the above success, I decided to take again a direct and forceful approach.  Here is an excerpt:

…it would be most prudent to repeat the ultrasound BEFORE we remove the portacath, so that we make sure the DVT is resolved (so that we do not risk dislodging a piece of blood clot that could go to the lungs).

Your company, however, has decided to deny coverage of a repeat ultrasound.

I would ask that you please reconsider this most expeditiously.

And reconsider it most expeditiously they did.  Again, within 24 hours, I had a letter of approval on my desk.  It seems that pointing out that their denial of the test could result in a potentially life-threatening consequence worked wonders in getting approval from the insurance company.

But again, I wished I didn’t have to go through this ludicrous process to get a clinically justifiable test approved.

Case #3

A tumor removed at surgery turned out to be a much higher stage than the preoperative testing had indicated.  I recommended adjuvant chemotherapy.  (Adjuvant chemotherapy is chemotherapy given after surgery, to decrease the chance of relapse in the future).  However, to make sure we will not be exposing the patient to the risks of intensive chemotherapy inappropriately, I recommend a CT scan to make sure there is not already metastatic disease. (If there is metastatic disease, the chemotherapy cannot change that, and we would instead recommend chemotherapy treatments with less risk of toxicities, to palliate the metastatic disease, but balance side effects with quality of life).

The surgeon had ordered a CT scan prior to the surgery, but the insurance company had denied it.  We re-ordered the scan urgently, with the hope to have results quickly, and scheduled the start of chemotherapy in one week.

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We received a denial of reimbursement for the CT scan.  This particular insurance company told us that they subcontracted this patient’s care to a subsidiary company.  We contacted that company.  They told us that, no, the parent insurance company is responsible for the decision on authorization.  After one week of repeated calls to both companies, we still did not have an answer.  We had to delay the start of chemotherapy.  After 2 more days, we finally received an authorization.

If I did not have a medical assistant whose primary responsibility is to help obtain these prior authorizations, I would never have been able to take care of the numerous back and forth phone calls that were necessary to finally obtain the approval.  No physician could do it alone.  (note to self – remember to bring coffee tomorrow for my prior authorization specialist MA).

Is there any hope for the future?

I think so.  I think physicians are starting to be heard.   A workgroup led by the AMA recently released a statement of Prior Authorization and Utilization Management Reform Principles.  I found an excellent summary on this blog post on medaxiom.com.

On their website, the AMA states:

The inefficiency and lack of transparency associated with prior authorization cost physician practices time and money. The lengthy processes may also have negative consequences for patient outcomes when treatment is delayed.

The AMA believes that prior authorization is overused and that existing processes are too difficult. … the AMA believes that prior authorization is a challenge that needs to be addressed through a multifaceted approach to reduce burdens on physicians and patients.

Here are some more blog posts that I found to be good reads:

https://www.nytimes.com/2014/08/04/opinion/adventures-in-prior-authorization.html

http://gomerblog.com/2017/02/prior-authorization-eternity/

http://www.fiercehealthcare.com/practices/physicians-frustration-prior-authorizations-only-grows

http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/insurance-companies/prior-authorization-predicament?page=0,0

http://www.physicianspractice.com/blog/obtaining-prior-authorization-three-success-strategies

http://drmintz.blogspot.com/2012/05/prior-authorizations-suck.html

Epilogue:

Case #1:  No CNS metastases

Case #2:  Portacath removed successfully

Case #3:  Patient able to start chemotherapy

These are just 3 examples of the 50+ patients I see in a week.  Next time your doctor is running late, think about the last test you had — now you have a glimpse into what happened behind the scenes to make that happen.

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