How pre-authorization paperwork may ironically raise health costs

Filling out pre-authorization paperwork is among the most frustrating chores a doctor can do.

But it’s going to continue, because of the rampant spending on prescription drugs and diagnostic tests. Throwing more obstacles in the way of doctors is a draconian way Medicare and other health insurers can reduce demand.

And it works. In the short-term anyways.

In a piece from NPR’s Shots, Scott Hensley discusses how Boston’s Massachusetts General Hospital changed its pre-authorization software program to force doctors to justify their tests: “The switch appeared to get doctors more involved in ordering of all scans, too. The proportion of scans ordered directly by doctors increased to 54 percent from 26 percent beforehand.”

Spending time justifying tests takes time which, as we know, isn’t valued in the outpatient setting.

I certainly support more evidence being required before ordering an expensive CT, MRI, or PET scan, but forcing doctors to fill out paperwork, or putting them on hold while on the telephone, doesn’t strike me as the best use of their time. Especially with the rooms filled with patients waiting to be seen.

There’s going to be a breaking point — which some doctors have already reached — where physicians are going to simply refer patients to specialists or to the ER rather than jumping through pre-authorization hoops.

And that, ironically, will only escalate health costs.

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  • Dr. Pi

    I agree that the urge to quickly refer to avoid the prolonged and uncompensated time it takes to get pre-authorization is tempting and time saving. When I did primary care, I was scheduled to see a patient every 10 minutes!! It was brutal and as you can imagine, any one sick enough to see a doctor needed more than 10 minutes of my time. I’m now doing sub-specialist work and am much. much happier. (And less guilty of shortchanging my patients.)

  • KP Internist

    Maintaining data on utilization by individual providers and reporting to that provider on how he/she compares to similar providers is most effective. It does change practice habit if you find that you order MRIs 10 times as often for the diagnosis of headache as your office mate with the same panel of patients. Of course, extreme outliers would also be targeted for measures to mediate excess usuage. This is a much more effective strategy than to punish providers that use good judgement to compensate for the ones that are too lazy to think.

  • stargirl65

    If I think you need an MRI or CT scan and they refuse preauth, I will send you to the ER or a specialist. They can fight with the system. Does this really save money? The test usual gets done eventually, after spending lots more money. The specialist usually throws in a few more procedures along the way as well.

    I require patients to come in for any prescription authorizations. This increases the cost of health care by adding one more appointment. The drugs rarely get refused. Occasionally they get changed to a similar medicine.

  • DocB

    a Prior Auth serves ONLY one purpose. it allows insurance companies to refuse payment for a service and put the “responsibility” of that squarely on the physicians.

    It makes me insane to hear a patient tell me they were told that the insurance “would” pay BUT that YOUR doctor has not done the prior auth (EVEN WHEN I HAVE DONE THE AUTH and the the INSURANCE company has DeNIED!!)

    plain and simple. Prior Auths should be illegal!!
    NO other profession would put up with this CRAP!!
    make it illegal or force the insurance companies to PAY us for the service of prior auths.

    gosh…. would love to see the AMA actually take up something important like this… instead of protecting plastic surgeons.

  • fortitude

    It seems all these things for utilization makes the PMD’s job that much more difficult, how much do they want from us for a lowsy 50-70 dollar visit? 50-60% is overhead so its more like 10-30 dollars and thats if there is no deductible which half the patients don’t even want to pay, so it ends up being a few bucks,

  • LynnB

    Several bad things happen when patients go to ER for 3 dimensional imaging studies. They typically do that after waiting > 2 weeks to hear if their scan is approved , or its been denied .

    1. They don;t get prehydration or hold diuretics prior to contrast
    2. The results are called to an ER doc and there is either no discussion or one that looks at a different , more immediate set of problems. If it isn’t a ruptured diverticulum that requires surgery , the ER doc may not care–his decision to admit or not is already made .
    3. The request doesn’t say “left upper quadrant pain for 6 weeks with weight loss” it says “acute abdomen” and the report is not as useful
    4. They are much more likley to have a procedure — like a laparoscopy or an MRCP or an EGD
    5. The ER often refers them to a specialist –God knows the PCP can’t order PPI’s .

    And yet, the patients are scared and worried and they have tried to play nice.

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