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

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 insurance company 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 patients, but must sacrifice my schedule and keep other patients 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 cancer of unknown primary.  As part of our work-up to find the origin of the cancer, 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 hope for no more episodes, my practice experience unfortunately tells me there will be more…)

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Also published on Medium.

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

  1. Fifteen years ago when my husband was being treated for esphogeal cancer that had grown into his stomach, the chemotherapy drug was approved but NOT the infusion into his body. I spent hours on the phone with the insurance representatives trying to find one who at long last understood the drug could not kill cancer cells sitting on a shelf!! Finally there was an ‘ah-ha’ moment when I was connected to a person who did understand & got the infusion approved!! Thank God for oncologists like Dr. Jennifer Lycette!

    • Thank you Gerry. I am so sorry to hear that you had to be on the phone yourself with the insurance companies. I am lucky that I do have staff to help me in this process. I don’t think patients or families should ever have to have this added to the stress they are already enduring. Thank you for taking the time to leave your comment. Remembering Jerry.

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