Patients and Physicians Speak Out

[Prior authorization affects my practice because] it delays patient care. The process is tedious, and the insurance companies are programmed to deny first. You are on the phone for hours waiting and when you finally reach someone, they often redirect you to another department or team where you have to wait again. The operators don't know or understand the procedure or what the patient needs to authorize something. They also can't answer your questions because they are not clinical. The insurance companies have hard and fast rules that do not take the patient into account. They will still deny procedures even when their own medical experts agree with your assessment and what the patient needs. "If the plan doesn't cover it, then there's nothing they can do." The entire process is burdensome and harms patient care.

I am a 2-person, single physician office. My office administrator is also a clinician with her own caseload. It takes me 20 minutes to complete prior auth documentation at a minimum.

Denials of coverage for meds then takes [my] office admin 30-45 min on the phone to do appeals. I then have to spend more time to pull articles supporting use of the named med in given situations, pulling research on alternative treatments that have been shown to be less effective, etc., in order to provide support to the [prior authorization] appeal. I do not accept insurance, in part because a small office in psychiatry does not have the income to sufficiently support dedicated prior auth staff, insurance billing staff, etc., to deal with insurance loopholes and frustrations.

A court determined that my patient's antipsychotic medication was necessary for preventing life-threatening behavior. The patient's family told me that they couldn't afford the medication without [prior authorization] through insurance. Insurance would not give me an option that met the patient's needs fast enough to reduce the risk of life-threatening behavior. It's a bit disappointing that the word "life-threatening," coming from the prescribing physician, isn't enough to move the ball when working with these insurance companies [on prior authorizations]. After hours on the phone with the insurance and pharmacy, well after business hours, our best option was to use an un-tested medication and a GoodRx coupon. I did not sleep well that night.

Sometimes [prior authorization] INCREASES the cost of care, which it is intended to combat. For example, certain higher level imaging studies are needed, no matter what, to evaluate for a condition. Carriers have blanket requirements that lower-level imaging be performed first, and in certain cases, this lower-level imaging will not help at all- it will not change the fact that the higher-level imaging is necessary. So, insurers are REQUIRING that we order two studies instead of one. The alternative is to send a patient through the ER, which is clearly not cost-effective for a condition [that] can be managed at the outpatient level. This is unnecessary, wasteful, and contributes to increased costs for all. All of this AND calling to do a "peer-to-peer" discussion has no impact: the "peer" can't waive the lower-level imaging requirement even when they medically agree, and it takes up at least 30 minutes of time, which would easily be 1-2 more patient visits.

One of my patients is an uncontrolled diabetic with an HbA1c>11%. She was started on insulin. She was able to get the insulin but was unable to use it because she needed a [prior authorization] for the insulin needles! This is ridiculous and extremely dangerous for the patients! -Mariam S., MD, VA

I am a pain management specialist, so nearly every one of my patients is on high-dose opioids. Nearly every single script I write requires prior authorization - even for what I would consider "reasonable" levels of chronic opioids (based on the patients I see, at least- NOT on what a PCP might encounter). Clearly, some of the problem is from the overly restrictive policies that have superseded physician judgment with "protocols and guidelines." Those protocols and guidelines have been created to address 90-95% of the patients that are seen in the normal course of routine practice.... yet nearly EVERY one of "my" patients falls into the 5-10% range of patients that are "outliers" due to their need for high-dose opioids.... which is the whole reason that they were referred to me in the first place.

For patients on high-dose opioids, having to wait for a prior authorization or a "discussion” ("fight") with a pharmacist, can risk putting them into acute opioid withdrawal. However, it also means that I routinely have to spend 30-60 minutes "above and beyond" the actual time spent with the patient and time spent charting. My only recourse is to now document all of that time in detail and "code accordingly," meaning that I am trying to get reimbursed for the additional time spent doing these prior authorizations. Although this is costing the insurance company a marginally increased amount of money, the amount generally does not adequately compensate me for my time and frustration. It greatly increases the patients' anxiety, as well. For "specialists," there really should be no excuse to demand additional paperwork [that] appears to be nothing but perfunctory.