Prior authorization and decision trees: Roots of my frustration

While I was in residency, one of the most annoying tasks given to us was “phone notes.” Every day, a pile of notes requiring our attention would show up in a box in the resident’s work room. Some would be patient requests for prescriptions, others would be from patients with questions about upcoming surgeries, and others would be information our attendings wanted us to call a patient about. But the most annoying were the prior authorizations.

As a small-town urologist, I no longer have to deal with (most) prior authorizations, as I pay my staff to do that. But not a day goes by when I don’t hear one of our nurses or secretaries on the phone trying to work through the automated decision tree to get permission for some medicine, test, or lab that I ordered.

Talk about a waste of time and resources.

And while I love urology and think we are a truly special group, I know that urologists are not unique in having to deal with this problem. From drugs to imaging tests to durable equipment, insurance companies create barriers to prevent doctors from being able to order the medicines, tests, and equipment that we deem necessary. I thought the purpose of medical school and residency was to learn what tests to order; I didn’t realize that I should have gone to insurance company school to learn that.

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Why am I so bothered? First, this is not a cost-free problem. While the data are a bit old, a study in 2013 estimated that the requirements for preauthorizations costs approximately $3,430 per doctor per year! Another slightly older study comparing Canada’s single-payer system to ours found that in 2011, the average Canadian physician spent $22,205 per year whereas the average American physician spent $82,975.

Second, on top of the cost, the stress and hassle that it creates for my staff are almost to the breaking point. Between talking to patients (which is something I have no problems asking my staff to do) and dealing with me (which can be challenging), my staff does not have the time to work through these decision trees whose only discernable purpose is to save the insurance company money. The number one complaint of my staff is having to prior authorize our tests, and the longer I run my practice the more aware I am becoming of the importance of keeping my staff happy. Happy staff interact with my patients in a better way and happy staff also interact with me in a better way.

Third, I find the concept of prior authorizations simply frustrating. One example: I have started to more frequently order prostatic MRIs as part of my elevated PSA/prostate cancer algorithm. The data behind this test are maturing well and, unlike some of the genetic tests, patients seem to intuitively understand the results. When I tell a patient who is reluctant to undergo a repeat biopsy that he has a suspicious lesion that I may have missed on the previous biopsy, simply based on its size or location, they get it. I haven’t found that to be the case when I give patients the printout from some genetic test and start talking about wolves in sheep’s clothing.

Next: The real problem I have with insurance companies

The real problem I have is that not every insurance company follows the Joint Consensus Statement from the AUA and Society of Abdominal Radiology, which states that prostatic MRI should be “strongly considered” in “any” patient with a prior negative biopsy “who has persistent clinical suspicion for prostate cancer.”

One recent example is a man in his 50s with an elevated PSA (6.0 ng/mL) but a negative biopsy 18 months ago. He did not tolerate the biopsy well from a pain standpoint and also developed a fever following the procedure. Biopsy showed no malignancy, but he missed all of his follow-up visits. A friend at his church was recently diagnosed with prostate cancer and he decided to get his PSA checked again via his primary care physician. It has doubled and is now 13. When he came to my office, he was obviously (and correctly) concerned but was almost in tears about the idea of a repeat biopsy unless it was absolutely necessary. We discussed the benefits of an MRI and I sent a very happy patient on his way.

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But the insurance company denied the request for his MRI. I even had our nurse repeat the online preauthorization process on the assumption she made a mistake; denied again. I called the insurance company to initiate a "peer-to-peer" review and after presenting the patient and even quoting the AUA consensus statement, I was again denied. Why? The insurance company's algorithm is that the biopsy needs to be within 6 months. I asked what data they based that on and was met with silence.

What can be done about this? While it may not help us urologists, at least the government acknowledges the problem and is trying to address it. Medicare recently attempted to streamline its prior authorization process for certain durable medical goods. Regarding the private insurance companies, I know of a much larger urology group than mine that went directly to the insurance companies and created agreed-upon criteria for various imaging tests. While that may work for a mega-group, I don't know how a small group like mine could accomplish that.

On the positive side, one of the radiology groups in town recently offered to have its staff do the prior authorizations and that is certainly helping (and gaining them business), but that is simply moving the problem from one doctor's office to another.

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Personally, I would like to see the patients get involved in the process. Specifically, if an insurance company denies a request, the patient should be given the responsibility to contact the insurance company and request it. Patients after all are the ones paying for the insurance. I somehow doubt that insurance companies would be as rude to their paying customers as they are to us. But then again, given my experience with insurance companies, maybe they would.

I think the only chance we have is to educate our patients on how insurance companies seek to limit access to medical care and, by bringing them into the process, have the insurance companies change their behavior.

But I'm not holding my breath.

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