How is your practice affected by prior authorizations?

September 1, 2015

"Over the past 10 years, it’s been getting progressively more challenging to schedule certain tests and treatments because of insurance companies’ hoops that we have to go through," says one urologist.

“I would definitely say it takes more time and has become more difficult. They’re definitely asking for more tests-like CT scans and imaging. There are more pre-authorizations and more difficulty and sometimes denials in cases that were never denied previously, such as kidney stones with CT scans. 

We usually get the authorizations eventually. Sometimes, we have to send in notes on the diagnoses and more clinical information; occasionally we have to get on the phone and discuss it with physicians representing the insurance company.

Also see: What’s your opinion on targeted biopsy for prostate cancer?

It can certainly be harmful to the patient when we have delayed imaging. Things can be delayed several days when there would not have been any delay. That can be a severe problem. It definitely costs more man-hours and time on the part of our office. It has probably required hiring more people. Over the passing years, it’s requiring more and more phone time.

The whole process is really unnecessary considering that they eventually approve things anyway; they’re really wasting their own time. Sometimes, for example, they come up with different rules as far as stipulating that you have to have an ultrasound before you can do a CT scan, so eventually the patient gets multiple tests. If we could just do the CT scan first, we would have the answer.

An ultrasound may rule out needing a CT scan, but then again you’re taking a risk of not getting adequate information and that can be detrimental to the patient if they have a stone that’s missed that the CT would’ve picked up. It can obviously be more expensive doing both tests, and insurance ends up paying for them.”

Chris Stage, MD
Shreveport, LA

NEXT: "Medications are more commonly a problem."

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Dr. Pidutti“I don’t think we’ve really been turned down for a procedure that we want to do. I don’t really remember that ever happening, but if you’re talking about having certain medications approved, yes. For a CT scan or MRI, they might say we need more documentation, but that is pretty uncommon. Maybe once every 3 to 4 months, I ask for a scan they don’t want to do. But actually on procedures, I can’t remember them saying ‘no’ to a procedure. Maybe most of the procedures I want to do are pretty routine and justified, but I can’t remember that happening.

Medications are more commonly a problem. Insurance companies are tightening up. Some of the newer ones-Myrbetriq is a new medicine I find pretty effective for a lot of patients-but a lot of these new medications are expensive. That’s a concern. The company actually has a helpline, and we can call that and see if they can’t get the tier lowered. We have to jump through hoops and we have to try two or three other medicines first.”

Richard Pidutti, MD
Johnstown, PA

NEXT: "It has been a challenge for a while."

 

Dr. Slavis“It has been a challenge for a while. I don’t notice it being any worse than it has been. It’s been bad for a while. It’s really tough sometimes. Certain drugs for bladder cancer-I just had a refusal. Getting MRIs for prostate evaluation for cancer [has also been a problem]. There are always obstacles, social issues that get in the way-demographics and insurance companies.

Typically, I eventually get the approvals, especially if they are important. Occasionally, I will say, ‘OK, we don’t really need that’; for example, if a patient wants a certain x-ray we didn’t really need to do, that I don’t feel that strongly about, I won’t push that hard. But if I feel strongly that something needs to be done, then I’ll make a person-to-person phone call to the insurance company and get it handled.

Over the past 10 years, it’s been getting progressively more challenging to schedule certain tests and treatments because of insurance companies’ hoops that we have to go through. And we know it’s not getting any better.

MRIs can be a challenge. Some pharmaceuticals can be a challenge when you have difficult patients who need second-line therapies.

I am going to say it isn’t really detrimental to my patients’ health, because I’m very proactive; I make sure it happens. We’re ready to do what needs to be done to get the patient taken care of.

I would say it’s a slow trend toward more and more challenges with insurance companies.”

Scott Slavis, MD
Las Vegas

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