Prior authorization required by health insurers impedes primary care

by Charles R. D’Agostino, MD

It strikes fear in the hearts of doctors across the country; it is not the deadly Ebola virus or a new strain of cancer, but its malignancy is equally apparent.

It is the dreaded “PA”, which is insurance-speak for “prior authorization” and it seems that no matter which way we turn it appears, standing between our patients and the care they need.

To their credit, PAs are truly equally opportunity barriers to care. Odds are that you will be required to get one regardless of whether you are young or old, male or female, or if you have the sniffles or a stromal tumor. And like magic, somehow they are filled out, submitted, denied, resubmitted, denied, telephoned about, put on hold for, resubmitted, and finally approved without you (the patient) ever lifting a finger.

Yes, the PA “dance” is too complicated for patients to learn; thus, we the physicians of overly-educated lore, and our countless staff members, are required to learn an array of delicate maneuvers determined by, and different for, each insurance partner we choose to dance with. And to make it a little more complicated, every so often they change the rules of the dance and usually forget to tell us or ask that we intuit the steps. As you might imagine, this causes a lot of toe stepping and even a fall now and again.

The most recent dance began three months ago. During a routine office visit, a patient shared with me that she was having difficulty with pain caused by her fibromyalgia and her symptoms were becoming increasingly severe and bringing her down. She had already tried a host of medications including SSRI’s, so we discussed trying a different medicine. I selected an agent (FDA approved for fibroymalgia), e-scribed it to the pharmacy, and then the dance began.

As they say, no good deed should go unpunished. It didn’t take long for the fax machine – recently renamed the denial machine – to start spitting papers into the office with the usual title: request denied. And so it began … we began filling out the requisite PA form which asked the usual questions: What was tried in the past? Why was the medicine needed? How did previous agents fail? How long would it be needed? That PA was promptly returned for insufficient data. No further explanation.

I called. “Sir, please enter the dates of prior trials with the recommended agents and return the form” intoned my dance partner. I followed her lead as closely as possible, despite the vanishingly low likelihood that she had anything that remotely resembled medical training. Nonetheless, the forms were re-completed and re-submitted, this time mentioning all other agents tried and approximate dates of the trials. We presumed success, due to a lack of response from the insurer (No news is good news or so they say) and we moved on to dance for the rest of our patients.

However, after some time had elapsed we learned that it was denied, again for insufficient data. Feeling perturbed, we banged out a personal letter pleading with them to authorize the prescription. No such luck. You see, when this insurer, which will remain nameless (Hint: It covers patients that probably cannot afford other insurance) asks for details, they want all the gory details. They want to know exact start and stop dates plus precise details on what side effects and (lack of) response the patient experienced.

We complied. My assistant did an exhaustive chart biopsy and filled out yet another PA form. Denied again! That evening I got a voicemail from a representative from the insurer. The next morning we called again and they claimed that the exhaustive analysis we submitted was never received. Nonetheless, they finally zapped over an approval to the denial machine the next day.

As I drove home that evening, I began to reflect on the whole dance-debacle. There seemed to be only a few conclusions that could be drawn from the experience. Either insurance companies don’t trust physicians to be honest with their requests or they have devised the most vile and devious of means to put up every roadblock in their power to save money. Either way it is a sad state of affairs. Obviously, we cannot put this kind of effort into every prescription, test, or procedure that I believe my patients need, and they know that. Translation: money saved.

Sadly, this scenario plays out every day of the week, every week of the year, in every physician’s office across the country. And although the dance wears us down and imparts unnecessary costs on our office in the form of both time and money, ultimately it’s the patients that suffer. Delays and denials have human consequences that insurers seem to fail to recognize.

A bright point on the horizon is an effort by the American Medical Association (AMA) to promote insurer practices that prevent the egregious ballroom antics described here, and similar practices that hurt patients and inhibit effective care. Last month, the AMA released its Insurer Code of Conduct which calls for insurers to adopt consistent practices (everyone is dancing the same dance), that will bring transparency and accountability to insurer practices.

Particularly germane to this example, are sections of the Code that state “no care may be denied on the grounds it is not “medically necessary” except by a physician qualified by education, training and expertise to evaluate the specific clinical issues”, “insurers must eliminate complexity and confusion from their processes and communications”, and “requirements … to obtain approvals and respond to information requests must be minimized and streamlined.”

The Code seems to have gained considerable support from medical societies (my own, Massachusetts Medical Society, signed on), but the real question is what will it take for patients to catch on that these reforms are needed and encourage insurers to adopt the Code?

Until then, we’ll keep shining up our old dance shoes for another tortured saunter through the grand ballroom of futile paperwork.

Charles R. D’Agostino is an internal medicine physician and hosts RadioMD, a weekly radio show.

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  • Christine

    I liked it when an obstetrician denied the PA my endocrinologist who specializes in diabetes submitted for an insulin pump and more than 100 test strips per month. Good times.

  • Janet

    Take no prisoners when doing PAs. I call after the first denial. I start the call with trying to get the evaluator to have some empathy for the patient’s situation. If they are a hard hearted hannah type, I ask for the person’s full name, credentials, and license number if they have one. When they ask why I want it, I tell them that I will put it in the file for the patient’s lawyer when the patient has a bad outcome so the family and lawyer know who is truly at fault. I also occasionally will ask them what part of their license gives them the right to practice medicine. These are valid questions to ask the insurance company representative. If they are going to be making the decision, they should take the liability. I have a very good approval track record using these techniques. It takes less time overall to just call after that first denial.

  • BladeDoc

    Gee, I can’t imagine why no-one wants to go into primary care.

    • Dr Pi

      This is one of the MANY reasons I left primary care.

  • Alice

    I love facetiousness……so point well-taken. We just had to get a prior authorization for my daughter’s neck dissection. They approved it for half the time the doctor asked for (I guess the nurse on the floor can request more). But the doctor’s office told me it’s doctors who work for the insurance company who are involved in the approvals.

    Which means it’s not that they distrust doctors, just doctors who don’t work for them.

    Out of curiosity, did the OB work for a different hospital than your endo? Not so sure dance lessons would help a patient….although, a few of our doctors seem to dance quite well (while others could use some lessons).

  • Chip Allen

    Ooh, this really touched a nerve. I don’t know how many times my doctors got caught up in the PA run around. It used to irritate me to no end to hear that insurance company bean counters were interfering with my medical care.

  • Doc99

    PA is yet another deleterious side-effect of the third party payor system. You forget another nasty one, Prior Approval/Authorization for a test/procedure does not guarantee PAYMENT for that test/procedure.

    • Vox Rusticus

      Better yet, the Blues in my area (Carefist) have tried yet a new tack: we call for a PA and are told that per the terms of the patient’s contract, no PA is required for a surgical procedure we have proposed. The same is told independently to the staff at the surgical center. The procedure is done and the claim submitted. The claim for payment is denied. Reason given: no prior authorization was obtained.

  • C. Staeheli

    The average time a physician spends each week on Managed care authorization issues is 3.5 hours. This is not reimbursed and this is not providing care. The average American family utilizes $5,500.00 in health care services annually but the Managed care companies are paid on average $13,000.00 from the employee and employer. Where does the other $7,500.00 go? Until we address this Managed Care white collar crime we will not cure the illness that is killing health care service in this country. Imagine if all $13,000.00 from every employed American actually went into one pool, what a system we could have. Imagine if the 3.5 hours spent on Managed care issues each week by every doctor was returned to actually providing care.

  • ninguem

    I think preauthorization at the appeals level should be considered the practice of medicine at the Board level. For that matter, so should peer review and medical expert testimony.

    Outrageous PA’s, testimony, peer review should be sanctioned at the level of medical licensure.

  • C. Staeheli

    I recently completed two authorizations on the same patient for one medication he has taken for 5 years and the other he has take for 4 months but the Managed Care authorization “dance” changed. The meds were denied so I put in my appeal, it stipulated only a doctor could provide the clinical info but I did not get to talk to a doctor on the other end. I was told the information would be forwarded to the “clinical team” for review. I do not know who the “clinical team” is. I received a call back and was approved for the first medication but only for the two specific doses AM and PM and was told any change in dose would require another authorization. The process took about 1.5 hours.The other medication was denied so I had to appeal to the next level. the first level was some thing called Prescription Solutions, the next level was the AARP plan and it was also denied there, The next level was United Health Care. Each level was not immediate and each took about 1.5 hours with my phone on speaker while I saw other patients and having them step out while I discussed clinical info. The denials came by fax the next day. The last level required and extensive clinical write up in addition to chart info I faxed in. After 72 hours from submitting the third appeal I received a call from “the reviewer” and the medication was approved. I think it helped that I filed a provider consumer concern about the risk of the patient not getting his medication with each company involved (because they all were subcontracted for varies aspects of the care) . The consumer representatives I talked to said all they could do is enter my concerns in a computer note to go to the reviewers. I had to cover the patietn with samples during the denial/delay process. I have learned each new “dance” but the steps are constantly changing and ever more complicated and time consuming. When I started Medical School I never thought the most challenging aspect of caring for my patients would be getting presriptions filled.

  • smartdoc

    I support reasonable PA for expensive or unproven treatments.

    However, some of what passes for PA is simply corporate criminal behavior, straight out of “The Rainmaker,” one of my favorite books (also a terrific movie with Matt Damon and Danny DeVito).

    This corporate misbehavior was ENCOURAGED not corrected in recent “health care reform.”

    • C. Staeheli

      Unfortunately Smart doc is right. The current health reform is forcing more Americans to buy into Managed Care so the Managed Care companies made out like bandits that is why despite healthcare reform their stock value is going up. Unfortunately Americans do not view the clockwork annual increase in Health Insurance premiums and copays as a tax but that is what it is in effect. I guess since it is not a government tax the Tea partiers have no complaint.

  • DocB

    I really dont understand why we even tolerate PAs. NO OTHER professionals would tolerate such a practice. it is a massive time and money waste for doctors… and nobody else.

    plain and simple…. it should be OUTLAWED!

    a PA only does one thing. it allows Ins Companies to refuse payment for care and then put the blame squarely on the doctor. it’s brilliant. “oh, we would be happy to pay for your MRI but your doctor has not submitted the proper PA…” despite the fact that I have done it twice and it ha been denied both times.

    2 simple fixes.

    1. just BAN it. insurance is between a patient and the company. they either pay for it, or they dont. make them explain directly to the patient why they wont pay for their medication.

    2. no prior approvals but if they want to have a review process…. then fine. you want an MRI? well you need 2 separate doctors agreeing that you need an MRI. you got 2, then you get your MRI. of course the ins company would haveto pay for both doctor visits…. so they wont like that.

    where is our AMA?????

    i’m afraid they are to busy making sure elective plastic surgery isnt taxed…… :(

  • Anon

    Some putative solutions to the PA problem –

    Charge the insurer for the time spent on working on PAs … it is not part of medical care, it is part of the financing of medical care, so it is not a traditional role of a doctor. If they wish to make medical care more complex, particularly so that they might save money, they need to pay for that

    Of course, they won’t, which brings up act two … charge the patient …. again, you are not practicing medicine, you are jousting w/ the Insurance company on the pts behalf to save the patient money … for if you did not do the PA, what should happen? The pt has to pay for the non-covered service themselves. In fair return for you working so hard to save them money, they should pay the doctor for the non-covered service

    Finally, if you deem it that doing a PA is part of the medical care, then keep the patient at your side for the duration of the dance, then document and charge the insurer for “extended care”

  • Marie

    I have maintained for many years that mediocrity, or clerical errors, such as ‘not receiving’ paperwork or providing incorrect information (stating something doesn’t need PA when it does), are tolerated way too often in the Managed Care world. There is no excuse for it.

    But after all these years of managed care, the tone of this article is primarily tiresome.

    First of all, let’s not forget that ‘denials’ are denials of coverage, not of care. So it is not the same as practicing medicine. That is a preposterous statement.

    Right, now the baying and the torch carrying mob will start: “well if the patient can’t afford it, it is the same as denying the care.”

    So there is the stalemate. The patient can’t afford care (or medication) you say is necessary. You can’t (or a pharmacy can’t) afford to/won’t provide the care for free. The insurance company maintains that there is not enough documentation to prove the service is medically necessary, therefore does not meet the standard for coverage.

    They won’t pay for it. You won’t pay for it. The patient won’t pay for it.

    So whose fault is it when something is not provided?

    Just asking.

    It is already the law in every state in the country that only a physician at an insurance company can deny a service for medical necessity. So that part of the AMA Insurer Code of Conduct is moot. “Bean counters”, that hackneyed and ignorant pejorative, do not make those decisions. After all this time if providers do not know that, then they are at fault for not understanding the system better.

    Yep, it’s a system. An imperfect one. Imperfect, like so many other things in this world. Insurance is a business, just like you are, just bigger, with more flaws. But if it wasn’t for health insurance, which goes right far more often than it goes wrong, what would people do?

    Inflammatory articles like this, short on reason and long on blame and childish analogies, just perpetuate the problems and ill feeling. Is your next article the one in which you provide your solution to astronomical healthcare costs so PA will no longer be an issue?

  • Christopher Staehelu

    Not sure if Marie has ever dealt with the Managed Care process from a provider end. Of course we all know the line from Managed Care ” I am not denying the care just the coverage,” I have been successful against every denial of coverage but the time spent has been astronomical. i am sure that I am not he only provider who has had to call the State Insurance Commisioner to get the care coverage authorized. It is rare to get the Medical Director the Managed Care company. Whether the by laws or code of conduct state only a Doctor can deny coverage may be tue but they do so through a layer of surrogates and rubber stamps. actually reaching a medical director takes a lot of time. Marie may be tired of the thread here but it is an important discussion as $13. 000.00 is paid to Managed care for each American Family and only $5,500.00 of medical services is utilized. So where does the other $7,500.00 go. The average physician spends 3.5 hours a week simply on Managed Care Authorizations not to mention the time Nurses and clerical staff spend. My question for Marie is simply: are you actually a provider of care or a denier?

  • Marie

    Christopher, I am neither a provider of care nor a denier. I am simply an observer at this point and expressed my opinion based on my experience. I am so grateful to Kevin that this forum exists so that there can be civil discussion on inflammatory issues like this.

    I agree with probably 99% of the comments that cite frustration at all the ridiculous hoops a provider has to jump through to obtain prior authorization. The process can be outrageous. Is outrageous most of the time, actually. There is no excuse for it. It is a tedious process because most managed care companies do not have their acts together. They operate under deplorable business models, in silos, with the left hand never knowing what the right hand is doing.

    It is especially despicable because these are people’s lives they are messing around with.

    But snide and sarcastic mind-sets get us nowhere. What is accomplished by stating the obvious in a derisive way that is also not accurate?

    It would be great if PA was never needed. Unfortunately, due to greed and poor management on both sides of this issue, something was needed to control costs. So there it is, a maddening part of doing business.

    Instead of whining about it, refuse to accept the mediocrity. Go straight to regulatory bodies. Demand to speak to medical directors. Work together to have your time coded so you get reimbursed for it. Don’t tolerate it.

    Write articles about challenging the system and how to be agents of change.

  • Christopher Staeheli

    Marie: everything you say is what those of us who practice medicine do already at a huge loss of time and energy that could be better utilized providing care. The Mnaged Care practice has not controlled cost,.so when you say “something had to be done to control costs” it comes across as if you actually believe the managed care approach was effective, it was not. Looking at the huge profits of managed care companies and the astronomical salaries of managed care executives, all that has happened with for profit managed care is a thievery of the finanacial resources for health care that could be far better utilized. Since you have no actual experience with the process perhaps consider that those writing here are trying to get the facts out there to create change. Certainly this is not the only place we submit our concerns. It is the American public that needs to get informed about what is really happening and this is just one place for that to happen. I hope that the thread here is not “tiresome” but is simply one more way to encourage/motivate change. I think most patients have no clue as to how hard doctors are fighting to just get prescriptions filled let alone diagnostic studies done and other treatments accomplished. Quite frankly I think most doctors are so tired from being on call every 3rd or 4th night and weekend and working nonstop 10 hour days and spending so much time on Managed Care bureaucracy that little energy and little time is left for healthcare reform.

    • Marie

      Christopher, you make excellent points.

      I do, however, believe in Managed Care as a way to reduce costs. I don’t have figures at my fingertips, but you have inspired me to do some research into the data. Perhaps we can race each other to see who comes up with the resulting article first? :)

      I also still maintain that action is better than empty complaining, but I take your point that physicians have their hands so full they are tapped.

      I would hope patients know how hard their doctors work for them. I know I do, and I work hard for my rights myself as well. I have Multiple Sclerosis and have engaged in many exchanges with my insurance company for coverage of everything from physical therapy to, currently, my new electric wheelchair. I won’t lie, it can be a challenge getting things accomplished. But when it does work, and as I said that is more often than not, it is a very good thing. My Tysabri alone, plus the oncologist’s fees where I receive it, runs over $3000 per month. My cost? None.

      I don’t have answers for all the flaws in the system and I fully acknowledge it is flawed. I continue to maintain change can only be effected by working together and taking real action.

    • tamoroso

      Gotta say I’m with Marie here.

      If you want PA to work better, work with managed care companies to make it better. Go to them and advocate for a better process. Make it clear based on statistics (“In the past year I had N cases, requiring M hours of PA time (be prepared to document the time spent), leading to X denials at a cost of Y to the patient, and Z approvals”. If Z ~= N, then you have a case; if Z << N, they are saving money, and you ought to show cause why they ought to stop a process which is saving money at apparently little cost to your patients. You also should look at what, exactly, M hours is, in proportion to your total workload.

      Prior authorizations are a PITA, no question. And because they are a PITA, time spent on them is magnified, compared to time spent doing things which are more rewarding. Managed care companies demand prior authorization because it saves them money, savings which they can (potentially) pass to patients (or, in the case of the likely insurer in the scenario written about here, taxpayers). If you are willing to pay more for an insurance plan which does not require prior authorization, I recommend you do so; I bet you can find one. If you can't (at an acceptable price), consider that PA requirements are likely a factor in the price you pay for insurance.

      I doubt insurance companies enjoy the PA process any more than you do. But when physicians insist on prescribing ondansetron for a problem which is adequately treated with metoclopramide, PA is needed to save the money which would otherwise be wasted buying steak for people who can manage just fine on burger.

      (And, for the record, I am an emergency physician, currently working freelance in the same Massachusetts Dr. D'Agostino works. MassHealth is a pain, but on the whole it works pretty well for both patients and taxpayers. Especially for the price paid-by both patients and taxpayers).

      • JustADoc

        Reglan had a black box added a couple of years ago which probably makes quite a few docs shy away from it. The lawyer are all over it in their commercials. I will spend the insurance companies money all day long in that scenario.

  • Alice

    It is the American public that needs to get informed about what is really happening and this is just one place for that to happen. [end quote]

    I agree that this is one place for that to happen, and I wish I didn’t find these boards so interesting (I just spent five days living at Cleveland Clinic, so the medical establishment is on my mind a lot). Overall, it seems *most* of the doctors there are quite happy in their jobs. Not sure if it’s strict management, or the selection process, or atmosphere.

    As more doctors are employed by big hospitals your time on insurance will be lowered, but in truth, you can try to inform the public, but when people pay for a service they aren’t usually that interested in how that service is provided. Just an analogy….do you worry about the people who slave to serve you at a restaurant? If the waitress pleaded her case when giving you the check would it change your mind, maybe you would want to help her and go to the back and help her fill in the bill (which is what some doctors on these boards actually seem to desire….they want patients to file their own forms. It’s really a preposterous supposition when you take it down the reality of where we are at with healthcare. So, the public reads this stuff and wonders how do doctors really view them)?

    If the American public is reading some of these threads and see that a small minority of doctors have an endless supply of whining against them it hurts the whole profession. And, in truth, I am old enough to remember doctors who really were in for the money (a majority of them, years ago) and they ruined the image for you. Another small minority of doctors give all of you a bad name, so excuse the American public for lacking in sympathy. It may just be an occupational hazard that was brought upon you by your own colleagues..

  • Christopher Staeheli

    There is no whining here against patients. The doctors writing here have a passion for a better healthcare system and it is unfair to mischaracterize this thread. Doctors make no money getting managed care authorization for a treatment or a study or a prescription. When a patient is in the office the visit is paid, it is the treatment that we have to fight for most of the time and that is no profit to the doc. We are fighting hard for our patients because we love treating patients. I am sure we would all be very unhappy if the waitress spent spent 3.5 hours a week caling across the country to get the meals paid for but the restaurant analogy does not fit well as people do not choose to get sick. As an employed doc I deal with Managed care Auths all the time. I could see several more patients a week if I did not, but my personal profit would not change. That is not what this discussion is about. The Managed Care Authorization and denial of coverage process is a business tool for rmaximizing profit by creating delay and inefficiency on the service end.

  • Alice

    There is no whining here against patients. The doctors writing here have a passion for a better healthcare system and it is unfair to mischaracterize this thread. Doctors make no money getting managed care authorization for a treatment or a study or a prescription [end quote]

    Not sure if you are talking about this particular thread or other threads on this huge board (others have some real rants against patients. On one a paramedic and others proclaimed terror at what doctors were saying about patients). I think you are broadly generalizing on an idealistic, philosophical type of basis (or, possibly, just your own view and practicing a type of defensive medicine?). I know sometimes I generalize, but in truth it’s a small minority of doctors who are really shady. I just can’t defend their actions (read some of the threads on peer reviews and see what patients know doctors are capable of).

    So….if care is denied…….the doctor makes no money (ack…rhetorical)? All that optional surgery would not be done. And even some life-saving surgery may not be done…….unless the doctor, hospital, and staff want to donate their services?

  • apurvab

    [quote]So….if care is denied…….the doctor makes no money (ack…rhetorical)? All that optional surgery would not be done. And even some life-saving surgery may not be done…….unless the doctor, hospital, and staff want to donate their services?[/quote]

    For outpatient care, which is what PCP’s generally do, pre-auths are mostly for medication, tests and imaging studies, none of which generate any money for the doctor, and are done solely for the patient. The occational prior-auth for a referral to see another doctor may make someone else money, but again, is of no value to the doctor who actually has to obtain the authorization, and is done for the patent’s benefit.

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