While many medical professionals like to voice their dissatisfaction regarding prior authorization (PA) they’re frustrating, time-consuming, and sometimes fruitless it is not merely talking. According to an AMA survey, 91% of physicians feel that PA can have a negative impact. Additionally, 82% believe that waiting for PA can lead to patients abandoning care, and 34% have seen PA result in a serious consequences.
Our medical decisions can be overturned by someone with no clinical experience. I recently had a podiatrist decide whether my patient needed a brain MRI. These “peers” in the peer-to-peer PA process are employed by the insurance company, with the goal to contain costs.
But PA often does the opposite. In another survey, 24% of physicians reported that failure to obtain a PA led to a hospitalization. Delays in PAs lead to late diagnoses, complications, and other negative outcomes. You tell me which costs more.
It is estimated that 41 PAs are done per physician per week, which is equal to 2 business days every week per staff and physician. Imagine how much care we could provide in those 2 days. In 2019, this came at a price tag of $528 million, and it has only been increasing. In 2022, 79% of doctors reported an increase in PA requirements.
As medicine advances, and we face more struggles with the COVID-19 pandemic and the aging population, we shouldn’t be forced to jump through hoops to get patients’ medical care. My own experience shows that please for services often fall on deaf ears. This useless coverage game is not good for patients, practices, or the economy.
When dealing with PA, it is often best to utilize someone with experience. Many nuances to obtain approval only come with that experience. When denials occur, appeals can be filed, although that can be a lengthy process. When one course of action is not approved, it helps to switch plans, such as referring a patient to an ENT surgeon when a general otolaryngologist is unable to obtain PA for surgery. If a patient needs an urgent test, escalating the request (e.g., asking to speak with the medical director) can help. If all else fails, every state has an insurance commissioner with whom a complaint can be filed.
