Beating the Prior Authorization Blues
Getting insurer approval for treatment can take hours out of your week. Here are some ways to reduce the pain.
Fam Pract Manag. 2016 Sep-Oct;23(5):15-19.
Author disclosure: no relevant financial affiliations disclosed.
Like many family physicians, W. Ryan Neuhofel, DO, has spent his share of time on the phone asking insurers for prior authorization of medications or medical procedures for his patients.
Unlike many physicians, Neuhofel decided to videotape it. The Lawrence, Kan.-based physician recorded a 21-minute call of himself seeking approval for a computerized tomography (CT) scan for a patient with a palpable mass on his skull and then posted the video on several social media platforms, where it attracted thousands of views.
“Apparently it struck a chord,” he said.
The call was shorter than the typical prior authorization request, Neuhofel said, but it was just the first of several prior authorization calls he had to make on behalf of the patient as concerned radiologists requested additional CT scans, a magnetic resonance image (MRI), and nuclear bone scans to help diagnose the tumor and see if it had metastasized from elsewhere.
The insurer ultimately approved all of the tests, but delays forced the patient to decide to undergo the scans before receiving insurer approval because of the possibility of cancer, he said.
Neuhofel has to seek prior authorization only a handful of times a month in his direct primary care practice. However, he said cases like this are especially frustrating because the medical need was clear and there was little chance the procedures would be denied.
“We feel like we're trying our best to advocate for our patient,” he said. “It creates that sense of angst that we want to help people and yet there's someone who is not really accountable who is straining that relationship of us being an advocate.”
Insurers and other payers have long used prior authorization as a valuable tool. Lydia Bartholomew, MD, of Edmonds, Wash., is a medical director for a national insurer and a member of the American Academy of Family Physician's (AAFP's) Commission on Quality and Practice. She said insurers require prior authorization to confirm that the treatment prescribed by the physician is covered by the patient's health plan and is the most appropriate care in the best setting. This helps insurers control health care costs by reducing duplication, waste, and unnecessary treatments, as well as identifying patients who might benefit from case management services, she said.
Of course, the tactic has real costs for physicians and their practices. One study estimated that primary care physicians spend an average of 3.5 hours a week dealing with insurers, and the entire medical community spends the equivalent of between $23 billion and $31 billion annually in time on insurance matters, including prior authorization.1
Prior authorization can also negatively affect quality of care. According to an American Medical Association survey, two-thirds of physicians said they waited at least a few days for preauthorization on tests, procedures, or medications, and between 10 percent and 13 percent said they waited for more than a week.2
1. Casalino LP, Nicholson S, Gans DN, et al. What does it cost physician practices to interact with health insurance plans?. Health Aff (Millwood). 2009;28(4):533–543.
2. Commins J. Prior authorization hurts patient care, AMA survey finds. HealthLeaders Media. Nov. 23, 2010. http://bit.ly/29rg5Lx. Accessed July 6, 2016.
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