What’s your biggest frustration with prior authorization?

Sep 03, 2019

"One is the delay in delivering care. If I order surgery that requires prior authorization, it won’t always come through in a timely manner, and that impacts patients’ quality of life," says one urologist.

Urology Times reached out to three urologists (selected randomly) and asked them each the following question: What’s your biggest frustration with prior authorization?

"One is the delay in delivering care. If I order surgery that requires prior authorization, it won’t always come through in a timely manner, and that impacts patients’ quality of life.

The second is the wear and tear on my nursing staff navigating the prior authorization process. It’s relatively thankless work, so it doesn’t enhance my team’s satisfaction.

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Even minor issues, like having a procedure approved as an inpatient procedure, and if we do it outpatient (same hospital, same operating room, same staff), the insurance company can deny payment. Our hospital lost about $2.7 million one year because the status of admission was incorrect. The care is delivered, but they declined payment because the right box wasn’t checked.

We also get denials and have to appeal things that shouldn’t be necessary. For example, for a patient with relatively severe Parkinson’s disease with urge incontinence, the insurance company wants me to prescribe an anticholinergic, which unfortunately significantly impacts the severity of Parkinson’s. Insurance will deny medication that won’t impact Parkinson’s, and it has to be appealed. Even then, it will cost more out of pocket or the patient won’t get the medication, more commonly the latter.

The denial is not a denial because ‘we don’t think your medical decision was correct’; the denial is because ‘this medication is our preferred medication.’ ”

Christopher Boelter, MD / Sartell, MN

Next:"A peer-to-peer review gets really time consuming"“Just the sheer amount of time it takes to get prior authorizations for routine care. We need standard workflows for standard things that fall under guideline recommendations. We should do prior authorizations to filter out unique or maybe not appropriate treatments. But often, we’re requesting prior authorizations for things that get approved 95% of the time or more. If it’s standardized, guideline-driven care that gets approved most of the time, why does it still require prior authorization?

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Insurance companies have no automated way to screen normal care, and our staff must still spend time filing paperwork. It seems like a delaying tactic to spread out payments to providers, and it delays patient care.

I also struggle, as a specialist who’s an expert-I’m a reconstructive urologist by training-when we call for prior authorizations, and the physicians we’re dealing with-especially peer to peer-are not experts in the field. They’re going off a ‘cookbook’ in terms of what to approve or not to approve. That’s frustrating.

A peer-to-peer review gets really time consuming. The reviewers may not be available when you call, and you can’t schedule in advance. You have to hang on the line a significant amount of time-20 minutes to a half hour-to get these coordinated.

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Even a regular prior authorization can take a half hour on the phone just to reach somebody. It’s significant and means we have to hire more personnel to handle the paperwork. That increases the cost of care.”

Joshua Broghammer, MD / Kansas City, KS

Next:"Sometimes, I get fed up and get on the phone myself"“As with many urologists, I’m super busy. It takes weeks and weeks to get in to see me. I’ve had to limit the time my staff spends on prior authorizations, particularly medications. It takes too much time away from patient care; that’s much more important.

So we have patients handle their own pre-authorizations-contacting insurance companies themselves for medication approval. That actually works pretty well, but my staff still sits on the phone sometimes for 15 to 20 minutes for medication authorization.

Testing, CT scans, and surgery are things patients can’t do on their own, so my staff works on those.

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We have a big military educational presence in Monterey, so I see a lot of military personnel and they’re all TRICARE patients. Their prior authorization routine is even more onerous.

Over the years, I’ve taken care of several high-ranking officers at the Presidio and asked why we have to go through prior authorization every time. In the last 15 years, I can’t recall ever being rejected. Every request for CT scans, surgery, or MRIs has been approved. So what’s the point of prior authorization, if they’re all going to be approved, other than to drive my office staff crazy?

Sometimes, I get fed up and get on the phone myself. When a retired family practitioner is on the other end, not only do they not know much about urology, they’ve never seen the patient. Within 30 seconds, it’s approved.

At one point, every staff member spent 1½ to 2 hours a day on prior approvals. I have a solo practice and can’t afford to pay these people to play these insurance games.”

David Flemming, MD / Monterey, CA