By Elizabeth S. Rowe, Ph.D., M.B.A.
The new practice of insurance companies requiring pre-authorization for every test and procedure is resulting in delay and denial of care, sometimes to the point of life threatening injury.
We at RNI have experienced several instances in which critical time-sensitive testing was denied by an insurance company pre-authorization process. Since the first stage of pre- authorization is often computer based, that stage can often be done at the time of service, and the testing done immediately. However, if the computer process results in denial, then the follow-up appeal process can take days and literally hours of staff and physician’s time. And if the patient has a critical need, the resulting delay or denial of care can result in permanent injury or even death, for example in the case of a suspected evolving stroke. One could ask whether the insurance company can be held liable for malpractice.
How did this situation come about? The practice of insurance companies requiring pre-authorization for certain testing and procedures is not new, but many abandoned it years ago because of the administrative cost on their end, and the fact that most initial pre-authorization denials were reversed on appeal. The end result was that it cost more to administer than it saved in payments to providers.
What has changed? Why is the administrative burden on insurance companies no longer preventing them from requiring pre-authorizations? The answer, no doubt, includes the emergence of computerized technology for processing pre authorization requests, and its much lower cost to the insurance industry. The insurance companies outsource the service to national companies such as EviCore that provide these services using complex computer algorithms to second-guess a physician’s decision to order a particular test for a particular patient. The attraction for the insurance company is a reduction in testing of their covered patients; however, the resulting consequences of denial and delay of care must still rest with them.
Pre-authorization may be reasonable in this day and age when many tests are being ordered by primary care physicians, incentivized by their hospital-employer, not for their own diagnosis of the patient, but in anticipation of what a specialist that they are going to send the patient to might want to see. Often this testing is inappropriate or unnecessary, and we at the RNI discourage our referring physicians from ordering testing before sending us a patient. We order testing only after we have seen the patient, and obtained their history and neurological exam, so we can determine testing that is actually needed.
But if pre authorization is a reasonable policy it must be based on reasonable grounds. An obscure computerized algorithm that lumps all providers and all patients into “big data” and then comes out with rules for a particular test ordered by a particular physician for a particular patient, is not going to be effective in the long run. Nor is a “peer to peer” appeal process where an anonymous voice over the phone is second-guessing a specialist who has a complex sick patient in front of him. This policy will not result in either lower cost or higher quality health care.
WHAT CAN WE AS PATIENTS DO ABOUT THIS PROBLEM?
1. If we get a refusal of testing that our physician feels is really necessary, we can pay out of our own pocket. However if our insurance company has not approved a test, even if we pay for it ourselves, it will not count toward our deductible.
2. We can ask our physicians to be sure and document these denials in our medical records, including the name and credentials of the “peer” who denied an appeal. It is unlikely that the “peer” on the other end of the phone has credentials to match those of the RNI physicians.
3. If the appeal process results in denial, we can contact our insurance company and complain; the more complaints they get the more likely they will be to reconsider their processes.
4. And we can change carriers. At RNI we have found that the insurance companies vary with regard to pre-authorizations, and some are much worse than others.
