Michael A. Ferragamo, MD, a urologist and nationally known coding, billing, and reimbursement expert in the specialty, shared a story he said is just one example of the toll prior authorization is taking on urologists and their patients.
A patient presented with gross hematuria. The urologist wanted to do a cystoscopy then in his office, but couldn’t because the patient needed prior authorization for the procedure. About a week later, when the urologist obtained authorization from the insurer, the patient no longer had bleeding and was convinced he was OK and no longer needed the suggested examination.
The practice with which Dr. Ferragamo works called the patient repeatedly and tried to get him to come in for the procedure, to no avail. Six months later, the hematuria started again, as it often does when people have bladder cancer, according to Dr. Ferragamo.
“And a bladder tumor was found. If he had had the cystoscopy at the time he was in the office, without the delay, we would have seen the bladder tumor and treated it promptly,” Dr. Ferragamo said. “The insurance preauthorization started the ball rolling, but delayed proper care. Fortunately, the tumor was low grade and low stage.”
The process of prior authorization, also known as preauthorization or pre-approval, requires that doctors and other providers obtain approval from insurers before providing certain types of care, including prescribing medications and diagnostic tests.
According to the American Medical Association’s document, “Prior authorization: The current landscape,” health plans often use preauthorization to restrict access to costly services and therapies.
According to the insurance industry, preauthorization helps patients get the most effective and efficient care.
“Health plans work with doctors and others to determine the best, most proven and most effective treatments for various conditions. This is particularly important when there are questions about efficacy of services or where there is a wide variation in how to treat a particular ailment,” said Cathryn Donaldson, director of communications and public affairs at America’s Health Insurance Plans.
“As drug costs continue to skyrocket, prior authorization can help ensure that patients are aware of treatments that may be as effective and less expensive. This, in turn, can lower out-of-pocket costs for the patient immediately, and for all Americans in the long run.”
Ask many doctors if they agree, and they don’t. They say they’re caught in the middle of an administrative nightmare while trying to provide quality care.