The evolution of prior authorizations

My old strategy for getting insurance approvals for imaging tests doesn’t seem to be working anymore.

I used to put my thinking in my office notes so that a reviewer at one of the imaging management companies would clearly see my rationale for ordering that CT scan or MRI my patient needed.

Now I am getting more and more requests to initiate a “peer-to-peer” call instead. My heart sinks every time; each one is a sure time robber. Even with today’s talk about paying for value and quality, I still live in a world where my “opportunity cost” is $7 per minute. That is what I must generate every minute of my work day. A five-minute call could mean one less patient visit for a skin rash or an ear infection or a patient call to communicate an important test result instead of sitting in a phone queue, listening to Barry Manilow tunes.

The other day, my “peer” was a nurse, a “near-peer” human filter, who listened to my story about why the abdominal and pelvic CT was necessary for my patient with abdominal pain, diarrhea, and elevated liver function tests but otherwise unremarkable blood work, including hepatitis titers. She instantly gave me an authorization number. Afterward, I asked, “Don’t you read our office notes these days?”

“No, we stopped doing that. In this case, we were told the patient had a lump.”

“I coded for the three symptoms.”

“But we need to know what you are looking for.”

“A rule out?”

“Yes.”

“But you can’t code for a diagnosis the patient doesn’t have, that’s insurance fraud.”

“Well, that’s what we need to know.”

“So I need to spell that out, if you don’t read my notes. You know, in many offices the one whose job it is to call you is a lay person.”

“And so is the person who answers the call at our end.”

And I thought my notes were still read by a medical person. I should have asked if they stopped reading the notes because they have gotten too long and cumbersome for them to read. I’m sure a radiologist who reviews imaging requests has an opportunity cost, or a must-save-the-company-per-minute cost, of a whole lot more than $7.

Note to self: Always add “r/o” after describing the symptoms.

Of course, in cases where there is no time for the Barry Manilow queue, it is a well-known fact that the emergency room doesn’t have to worry about prior authorizations.

“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.

Image credit: Shutterstock.com

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