Prior authorizations deny patients necessary medical care

January 10, 2023

4 minutes to read

Resume/Disclosures

Personal Biography:

Shikha Jin
MD,
FACP
Assistant Professor of Medicine with a position in the Department of Hematology, Oncology, and Cell Therapy at the University of Illinois Cancer Center at Chicago and consulting medical editor for Healio Women in Oncology. They can be reached at sjain03@gmail.com.

Disclosures:
Jane reports serving as consulting medical editor for Women in Oncology and host of the Oncology Overdrive podcast.


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Our healthcare system is broken on multiple levels.

As a medical community, we seem to be hastening its untimely demise by continuing to engage in systems that waste an enormous amount of time and result in suboptimal patient care, such as previous procedures that are cumbersome, ineffective, time-consuming, and generally unnecessary. authorization system.

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perfect storm

The prior authorization system is extremely detrimental to patient care and results in unnecessary delays and disruption. As explained by the AMA, a prior authorization system costs valuable time, gets between the doctor and the patient, undermines the doctor’s expertise, does not put patients first and prevents patients from receiving the care they need.

How many hours do you think a doctor, nurse, nurse practitioner, pharmacist, and many others spend (waste) on the phone, justifying care through peer-to-peer calls and dealing with pre-authorizations? How many patients have their care delayed due to pre-authorizations or peer-to-peer denials of necessary treatments?

We also have to factor in further delays due to the inflexible blanket system for responding to these prior authorizations that don’t take into account the incredibly busy practices of physicians and the myriad of other responsibilities that need to be completed during the day.

Add to those legacy communication systems — yes, we continue to use fax machines and pagers in healthcare settings — extreme burnout as we enter the fourth year of an ongoing pandemic, significant staffing shortages, supply chain issues, and an all-out collapse of our healthcare system, and we have a perfect storm.

tedious process

The prior authorization process is set up to minimize waste and allow for plans to assess whether care is medically necessary. The argument consistently made by insurers has been that unnecessary examinations, interventions, and medical care are being requested, and the insurer should be able to determine if the care is necessary.

This process, in fact, does exactly the opposite and often results in patients being denied sophisticated, sometimes standard, medical care.

Medicare, especially in areas like oncology, often moves faster than the insurers’ protocol builders. The prior authorization system results in delays or eventual denials of care that must be approved and, in some cases, initiated in an urgent manner.

It’s not just new drugs or imaging modalities that get rejected or deemed necessary for prior authorization. Standard care treatments and interventions can also be forced to go through the prior authorization process. In some cases, the process results in a denial of care the patient has been receiving for years, but due to changes in insurance company protocol, a new prior authorization is required to justify this.

All of these barriers to timely delivery of care result in unnecessary delays and additional stress for patients and healthcare providers, who must allocate the necessary time to go through a tedious and often unnecessary process. In many cases, the individual making the decision to decline care is not even an expert in the field in which the care is being provided, and the insurance company’s protocols and policies are often not as up to date as the physicians providing the care.

The end result is that physicians and healthcare teams waste countless hours on the phone, justifying how we, as healthcare providers, deliver the care we are trained and board certified to provide.

I hear about doctors applauding them for going the extra mile for a patient and fighting for a particular drug or test. When this procedure must be performed for most patients in the clinic, there are not enough hours in the day to provide exceptional patient care and fight to make sure the care is then approved through the insurance company and eventually delivered.

The system currently in place is not helping patients get the best possible care; Instead, it was created to save money for insurance companies.

Many physicians don’t have the time to go through the lengthy and often inconvenient pre-authorization process for each patient, which is a win for insurance companies. They no longer need to pay for care that the medical provider has deemed necessary. Some doctors have simply given up on going through the process. I know of some practices that hire team members to only handle the pre-authorization process – a waste of resources and money.

Rescue a broken system

Physicians providing care are required to train for many years in medical school, residency, and in some cases, fellowship, and are required to hold board certification in their area of ​​expertise.

Why should we trust individuals who have no medical experience or training in this field to make life-altering decisions over the actual medical experts who provide care? If we don’t trust our doctors to order medications, interventions, or tests, why go to the doctor at all? If insurance companies knew best, then we should simply remove doctors’ offices and physicians from the equation, and insurance companies should be the ones diagnosing and providing care.

There are certainly some physicians who provide care that may not be up to standards, and systems need to be in place to address these issues. But punishing an entire healthcare system for a few bad actors doesn’t work; Instead, it leads to suboptimal care for patients across the country.

In a country where we pride ourselves on being at the forefront of science and medical care, it is pointless to refuse care because insurance companies’ protocols have not yet been updated, or because the insurance company simply does not want to pay.

As we enter the fourth year of an ongoing pandemic, massive cracks, inefficiencies, and gaps within our healthcare systems are being exposed. Now is the time to overhaul our system, and rebuild the foundations of patient care, with an emphasis on the doctor-patient relationship. It is time to return to patient-centered care. Eliminating the tedious, glitchy, and faulty process like the pre-authorization system is a good first step in making the changes needed to save the broken health care system.

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