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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