June 26, 2013
Most days dealing with Medicare and the major insurers is like being in “Alice in Wonderland.” There are rules upon rules, all designed to ask one, all important question. “Doctor, do you really want to order that test, do that procedure, or request a specialty referral?”
Medicare and the insurers make docs jump through expensive and extensive hoops in order to accomplish any of the previously mentioned tasks. Tasks, such as ordering a CT, require “prior authorization.” I have written about “prior authorizations” before.
Today, I saw a middle-aged business exec who plays full contact sports. During a weekend game, he managed to ram his head into the elbow of another player, leaving him with a skyscraper of a lump on his forehead and a concussion. I ordered a CT of his brain due to the extent of the injury and his bothersome symptoms. In the old days, prior authorization meant I authorized (ordered) the test before it was done. I did not assign a number as that would have been a waste of time.
Today, I had to put my patient on hold. I had to go to a computer, log on to a third party site that supervises physicians for the insurance company, answer all kinds of important questions (what’s my first born child’s name, what’s the 16 digit insurance number on my patient’s chart, why I want to waste my time filling in blanks and hitting enter) and wait for a response. Ten minutes later, I’m pleased to learn that this particular patient’s policy does not require a “prior authorization” code for this particular procedure.
So what’s the purpose of all this? Simply put, I’m being trained not to order CT’s. There is a strong, negative, financial incentive to performing any procedure that requires “prior authorization.” I spent (wasted) 10 minutes of my time. Ten minutes that should have been spent in patient care. I was not reimbursed for 10 minutes of time. I could have turned it over to one of my staff but she would have taken 30 minutes; and my patient’s care would have been on hold for three times as long.
I could have sent him to the ER. He would have waited in the ER lobby for hours and driven the cost of a CT through the ceiling. Worse, he could have had a subdural hematoma (clot on the brain) and precious time was ticking away as I was being re-educated by an insurer seeking to increase its profit margin.
I’m stubborn and feisty and refuse to give in. I order what my patient needs; and, when necessary, I fight for my patients rights. I’m stupid. It costs me money to fight these battles. What scares me is how many necessary tests aren’t done because smart physicians learn not to order tests that need “prior authorization.” There must be a lot or why else would insurers and Medicare make docs jump through so many hoops while caring for their patients.
So, what’s the big deal? Quit complaining, it’s just 10 minutes. Yes, it’s just 10 minutes per procedure or test ordered. On a bad day, I might order six tests, that’s an hour of time I’m not seeing patients or 3 hours of my staff’s time. The time spent on obtaining “prior authorization” is non-reimbursed time. In other words, it increases my overhead!
It’s also represents a 1-3 hour delay in patient care, late appointments, loss of staff and physician job satisfaction, all to increase the profit margins of an industry bloated with profits and craving more.