Patients and Physicians Speak Out

I have had to make multiple calls and wait as long as 2 weeks trying to obtain authorization for an MRI when there were abnormal mammogram or pelvic sonogram findings. The patients become increasingly anxious about their condition and sometimes angry at me because they think I’m either withholding care or not concerned about their needs.

We did a project to track what percentage of prior authorization requests from my private rheumatology practice were approved in 12/2017-1/2018. It was a 95% approval rate—some after 4 appeals, and countless hours of time and effort. The delays it causes prolongs patient pain and suffering and leaves patients vulnerable to permanent joint damage and in some cases organ damage while waiting for this unnecessary administrative barrier to be surmounted. Enough is enough...

Patients come to me for help, but I am shut down by the prior authorization system routinely. I cannot recall a single antibiotic that has been approved without PA except for Bactrim in the past 3 months. Imagine, a urologist is not allowed to prescribe for immediate treatment of UTIs. I get less hassle for CT scans actually. The whole PA program is a farce anyway. All they do is ask me if I really need the medicine and did I try another. If they have another suggestion it should be made automatically and I should have the ability to bypass it. They even reject antibiotics that are free at local pharmacies. It is absurd and wasteful and harmful.

Prior authorizations are the hidden additional cost of delivering healthcare. Each physician needs one full time staff member just to obtain prior authorizations. Items such as durable medical equipment, walking casts or splints costing less than $150 require at least 15-20 minutes of staff time for a prior authorization. This isn't the delivery of healthcare, this is rationing health services by making it too burdensome for patients to use the health insurance they are paying for.

My patient met the insurance company's prior authorization criteria, which was reasonable. Yet, the authorization was rejected, so I appealed. It was rejected again, even though I pointed out to the agent on the other end of the line that the patient met the criteria. I was about to give up, but decided to call the medical director of the insurance company instead, who granted authorization. I wonder how many people would have given up rather than continue the fight and how much money the insurance company thought it was saving by denying legitimate drug use.

I work at a urology practice. When I started here the only procedures requiring prior authorizations were surgeries. Now medications, radiology, and in-office procedures require prior authorization or you do not get paid. Often new prior authorization requirements are buried deep within some emailed network bulletin. Insurers are famous for changing prior authorization requirements. They just started requiring us to request prior authorizations on all chemo medications injected or infused through a portal. The questions are often confusing and time consuming even to the physicians. We have had patients that have had to put off certain treatments because it takes so long to get a prior authorization back or the hoops we have to jump through are increasingly tedious.