An oft-repeated phrase that dates back to the 4th century BC is that physicians shouldn\’t do harm first when treating patients. Nowadays, insurance companies that report to their investors and not to Hippocrates often prioritize monetary gains over patient care. Prior authorization is one way that insurance companies protect their profits and sometimes cause harm to patients in the process.
Prior authorization is defined by the American Medical Association as a cost control process that requires providers to qualify for payment by obtaining approval before performing a medical service.
For example, a doctor may need to obtain prior authorization from an insurance company for the use of a particular drug so that the insurer can determine whether the drug is medically appropriate and safe for use by part of the patient before the company agrees to pay him .
Insurance companies say the prior authorization process reduces medical costs by finding lower-cost alternatives and ensuring care isn\’t duplicated. A doctor who orders an imaging test such as an MRI, for example, may not know that the patient recently received one at another hospital.
However, a recent AMA survey of more than 1,000 physicians found that 93% reported delays in treatment waiting for insurers to authorize needed care, and more than 50% said earlier authorizations led to them being dropped. treatment due to patient difficulties navigating the prior authorization process. Even more alarming, 34% said serious adverse events, including disability and death, occurred while patients waited for their prior authorization.
In Texas, the Texas Medical Association reported that 79% of patients dropped out of treatment due to the prior authorization process. Additionally, only 15% of physicians found that the pre-authorization criteria of their patients\’ health insurance plans were evidence-based, meaning that in the majority of cases the criteria used by insurance companies to determine whether a patient needed the treatment required were not based on good medicine.
A recent study published in the Annals of Internal Medicine found that doctors spend an extra two hours on electronic health records and pre-clearances for every hour they spend face-to-face with their patients. Physician offices complete approximately 45 prior authorizations per physician, which equates to two working days a week that physicians and staff are absent from patient care.
The American Society of Clinical Oncology highlights some prior authorization denial scenarios that, fortunately, were reversed after the physician\’s appeal determined that the denials were based on errors and incorrect data review.
In one case, an elderly patient with cancer of the lining of the uterus was denied a CT scan of the pelvic area. In another, a patient with multiple myeloma, a cancer of the white blood cells, was denied a blood draw. While these patients did eventually receive the care they needed, the appeals process was time-consuming and exacerbated the delay in the care they already received while awaiting prior authorization. For cancer patients, these delays are not only emotionally stressful, they also allow the disease to progress.
Insurance companies only seem to make things worse. Beginning June 1, the Texas Medical Association reports, UnitedHealthcare, the largest health insurance company by revenue, will require separate prior authorizations for procedures such as upper endoscopies and diagnostic and surveillance colonoscopies, citing overusage. New prior authorization requirements for these procedures will inevitably cause patients to wait longer for medical treatment.
To reform the prior authorization process, the AMA has advocated reforms working to eliminate prior authorizations for duly approved treatments, establish gold card programs that exempt physicians from prior authorization requests as long as 90 percent of their requests are been approved in the previous 12 months, and force insurance companies to respond within 24-48 hours of the request so as not to delay treatment. In addition, insurance companies should be required to disclose prior authorization data relating to approvals, denials, appeals and waiting times.
After all, unless the insurance companies are held accountable for their inaction, patients will continue to suffer for the sake of profit.
Brian Rezel Carr is a Dallas-based oral and maxillofacial surgeon. He wrote this for The Dallas Morning News.
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