Getting the prior authorization runaround

When I first started with this practice, our local imaging facilities took care of obtaining authorizations for the CT scans and MRI studies that I ordered. It is easy for them; they know just what to say to get insurance providers to pay for these costly tests.

But of course, this is exactly the kind of conflict of interest that we try to avoid in medicine, so about 2 years ago the largest private insurer in Rhode Island changed the rules. This is an entirely reasonable change. But it is also quite inconvenient and time consuming, and, ultimately, it is not clear that it is saving the health care industry all that much money.

Today, if I want an imaging procedure done, I need to get approval for it myself. This usually means my secretary fills out the initial paperwork, the request gets denied, and then, after a series of faxes and phone tag that can take days to weeks, I get on the phone with a physician somewhere else in the world who is purportedly helping me make better patient-care decisions.

Some months ago I was trying to get an approval for a CT scan of the chest for a patient whom I suspected of having sarcoidosis. After an initial denial by the insurance company, I finally got hold of a physician for a "peer-to-peer" evaluation. The person on the other end of the line was a radiologist. He denied my request for a CT scan because the chest x-ray had not shown any evidence of sarcoidosis. Of course, I argued, that was precisely the reason I needed the CT scan. I also respectfully suggested that, being a radiologist, he ought to know.

If it were truly a peer-to-peer evaluation, the person on the other end of the line would have the ability to understand my reasoning, and would have sound counterarguments. If the idea is to reduce the cost of health care, then it is the job of the person on the other end of the line to educate me about why I might be wrong or let me know of alternatives that are cheaper, but no less valuable, that I may have overlooked. It’s either that or recognize that there aren’t any alternatives, and that I have exercised careful decision making.

Instead, all they do is pose questions to me, and then, after having made the patient, my staff, and myself go through all the trouble, finally approve my request. The goal ought to be thoughtful collaboration that ultimately drives health care costs down. Instead, it feels like the goal is to actively discourage me from making more requests by making the process too onerous.

My so-called peers would understand that my elderly patient on Coumadin might be better off with a Lidoderm patch than with some other systemic alternatives. If they were truly my peers, they would understand why it is royally unreasonable to withhold infliximab from a patient who has been doing well on it for years. More recently, because Blue Cross & Blue Shield of Rhode Island started using a new pharmacy benefits manager, we’ve even had to fill out prior authorization requests for methotrexate and prednisone. Do they really think we’re cavalier about writing prescriptions for such toxic medications?

Also, how much money are they saving, exactly? They probably spend a lot more money employing people to do this work than they are saving by denying these prescriptions, some of which are generic. In addition, there’s the cost to my patients’ productivity when they take time out of work. Certainly, it would be cheaper for the insurance company to pay for the cost of Voltaren gel rather than pay for a GI bleed requiring hospitalization, blood transfusions, and possible invasive interventions.

The rising cost of health care in the United States has not led to improved patient outcomes. It begs the question: How much of the increased cost is because of the increasing administrative hurdles?

Dr. Chan practices rheumatology in Pawtucket, R.I.

When I first started with this practice, our local imaging facilities took care of obtaining authorizations for the CT scans and MRI studies that I ordered. It is easy for them; they know just what to say to get insurance providers to pay for these costly tests.

But of course, this is exactly the kind of conflict of interest that we try to avoid in medicine, so about 2 years ago the largest private insurer in Rhode Island changed the rules. This is an entirely reasonable change. But it is also quite inconvenient and time consuming, and, ultimately, it is not clear that it is saving the health care industry all that much money.

Today, if I want an imaging procedure done, I need to get approval for it myself. This usually means my secretary fills out the initial paperwork, the request gets denied, and then, after a series of faxes and phone tag that can take days to weeks, I get on the phone with a physician somewhere else in the world who is purportedly helping me make better patient-care decisions.

Some months ago I was trying to get an approval for a CT scan of the chest for a patient whom I suspected of having sarcoidosis. After an initial denial by the insurance company, I finally got hold of a physician for a "peer-to-peer" evaluation. The person on the other end of the line was a radiologist. He denied my request for a CT scan because the chest x-ray had not shown any evidence of sarcoidosis. Of course, I argued, that was precisely the reason I needed the CT scan. I also respectfully suggested that, being a radiologist, he ought to know.

If it were truly a peer-to-peer evaluation, the person on the other end of the line would have the ability to understand my reasoning, and would have sound counterarguments. If the idea is to reduce the cost of health care, then it is the job of the person on the other end of the line to educate me about why I might be wrong or let me know of alternatives that are cheaper, but no less valuable, that I may have overlooked. It’s either that or recognize that there aren’t any alternatives, and that I have exercised careful decision making.

Instead, all they do is pose questions to me, and then, after having made the patient, my staff, and myself go through all the trouble, finally approve my request. The goal ought to be thoughtful collaboration that ultimately drives health care costs down. Instead, it feels like the goal is to actively discourage me from making more requests by making the process too onerous.

My so-called peers would understand that my elderly patient on Coumadin might be better off with a Lidoderm patch than with some other systemic alternatives. If they were truly my peers, they would understand why it is royally unreasonable to withhold infliximab from a patient who has been doing well on it for years. More recently, because Blue Cross & Blue Shield of Rhode Island started using a new pharmacy benefits manager, we’ve even had to fill out prior authorization requests for methotrexate and prednisone. Do they really think we’re cavalier about writing prescriptions for such toxic medications?

Also, how much money are they saving, exactly? They probably spend a lot more money employing people to do this work than they are saving by denying these prescriptions, some of which are generic. In addition, there’s the cost to my patients’ productivity when they take time out of work. Certainly, it would be cheaper for the insurance company to pay for the cost of Voltaren gel rather than pay for a GI bleed requiring hospitalization, blood transfusions, and possible invasive interventions.

The rising cost of health care in the United States has not led to improved patient outcomes. It begs the question: How much of the increased cost is because of the increasing administrative hurdles?

Dr. Chan practices rheumatology in Pawtucket, R.I.

When I first started with this practice, our local imaging facilities took care of obtaining authorizations for the CT scans and MRI studies that I ordered. It is easy for them; they know just what to say to get insurance providers to pay for these costly tests.

But of course, this is exactly the kind of conflict of interest that we try to avoid in medicine, so about 2 years ago the largest private insurer in Rhode Island changed the rules. This is an entirely reasonable change. But it is also quite inconvenient and time consuming, and, ultimately, it is not clear that it is saving the health care industry all that much money.

Today, if I want an imaging procedure done, I need to get approval for it myself. This usually means my secretary fills out the initial paperwork, the request gets denied, and then, after a series of faxes and phone tag that can take days to weeks, I get on the phone with a physician somewhere else in the world who is purportedly helping me make better patient-care decisions.

Some months ago I was trying to get an approval for a CT scan of the chest for a patient whom I suspected of having sarcoidosis. After an initial denial by the insurance company, I finally got hold of a physician for a "peer-to-peer" evaluation. The person on the other end of the line was a radiologist. He denied my request for a CT scan because the chest x-ray had not shown any evidence of sarcoidosis. Of course, I argued, that was precisely the reason I needed the CT scan. I also respectfully suggested that, being a radiologist, he ought to know.

If it were truly a peer-to-peer evaluation, the person on the other end of the line would have the ability to understand my reasoning, and would have sound counterarguments. If the idea is to reduce the cost of health care, then it is the job of the person on the other end of the line to educate me about why I might be wrong or let me know of alternatives that are cheaper, but no less valuable, that I may have overlooked. It’s either that or recognize that there aren’t any alternatives, and that I have exercised careful decision making.

Instead, all they do is pose questions to me, and then, after having made the patient, my staff, and myself go through all the trouble, finally approve my request. The goal ought to be thoughtful collaboration that ultimately drives health care costs down. Instead, it feels like the goal is to actively discourage me from making more requests by making the process too onerous.

My so-called peers would understand that my elderly patient on Coumadin might be better off with a Lidoderm patch than with some other systemic alternatives. If they were truly my peers, they would understand why it is royally unreasonable to withhold infliximab from a patient who has been doing well on it for years. More recently, because Blue Cross & Blue Shield of Rhode Island started using a new pharmacy benefits manager, we’ve even had to fill out prior authorization requests for methotrexate and prednisone. Do they really think we’re cavalier about writing prescriptions for such toxic medications?

Also, how much money are they saving, exactly? They probably spend a lot more money employing people to do this work than they are saving by denying these prescriptions, some of which are generic. In addition, there’s the cost to my patients’ productivity when they take time out of work. Certainly, it would be cheaper for the insurance company to pay for the cost of Voltaren gel rather than pay for a GI bleed requiring hospitalization, blood transfusions, and possible invasive interventions.

The rising cost of health care in the United States has not led to improved patient outcomes. It begs the question: How much of the increased cost is because of the increasing administrative hurdles?

Dr. Chan practices rheumatology in Pawtucket, R.I.