Docs Blame Prior Authorization

[somarco]

One in three physicians blamed prior authorization for a patient's serious adverse event, including hospitalization, permanent impairment, or death, according to a survey in a new tab or window published by the American Medical Association (AMA) on Monday.

In addition, 86% of physicians surveyed said prior authorization rules led to greater use of healthcare resources overall.
https://www.medpagetoday.com/primarycare/generalprimarycare/103515

 

[sshafran]

One in three physicians blamed prior authorization for a patient's serious adverse event, including hospitalization, permanent impairment, or death, according to a survey in a new tab or window published by the American Medical Association (AMA) on Monday.

In addition, 86% of physicians surveyed said prior authorization rules led to greater use of healthcare resources overall.
https://www.medpagetoday.com/primarycare/generalprimarycare/103515

I know there's "real world" and then there's theory.

Enter the theory realm.

If I'm a doctor - is it ethical to allow a lack of prior authorization to prevent hospitalization, permanent impairment, or death?

Does it indicate, essentially, that the doctor won't treat until he knows he'll be paid? As an agent I discuss options prior to knowing I'll be paid.

i.e. if immediate treatment is needed, why are they waiting?

Again, I know the real world works differently than theory.

 

[Midlevel]

Ask any Sales Manager for MAPD plans why prior authorization is either held up or delayed and they will tell you 9 out of 10 times it's because they were waiting for information from the Drs. office that they have failed to provide. I don't run into it often but that has been the case nearly every time. Those offices are quick to blame Aetna or UH or whoever and many times it's their end holding it up.

 

[scagnt83]

Unless MAPD is drastically different than groups, prior authorization takes apx 2 days in most cases.... assuming the Dr office has provided the required info... which in my experience was usually the main issue. Emergency situations are not subject to it.

Of course doctors dont want to take accountability for patient deaths.... lol.

But saying prior authorization is the cause does not mean its the insurers fault. There are 2 parties involved in that situation... no different than consumers saying DI claims are denied when they have failed to provide the required documents...

 

[sman]

Live look at doctors and insurance admins

 

[ICACharleston]

This thread could have started with "Two out of three doctors don't blame prior authorization........."

 

[somarco]

When your are the patient in pain, or anxious to get a definitive diagnosis, theory no longer applies.

I know many of the agents say no one contacts them about problems but that is not my experience. There are a number of folks who contact me, usually by referral, who are frustrated with PA, and want to change to OM + Medigap.

Theory says 2 - 3 days for PA, the ones who call me are waiting weeks or even months. That may not be your reality, but it is for the ones who are looking for an alternative.

Feel free to stick your head back in the sand, or wherever you put it, and carry on.

 

[KandKsmommy]

I know there's "real world" and then there's theory.

Enter the theory realm.

If I'm a doctor - is it ethical to allow a lack of prior authorization to prevent hospitalization, permanent impairment, or death?

Does it indicate, essentially, that the doctor won't treat until he knows he'll be paid? As an agent I discuss options prior to knowing I'll be paid.

i.e. if immediate treatment is needed, why are they waiting?

Again, I know the real world works differently than theory.

Ok so prior to switching to the agent side I actually worked in hospital billing.
Certain carrier are notorious for giving providers a hard time without saying names it starts with a W. I have had scans to check cancer progression denied, forced discharges on psych patients 3 days after a suicide attempt, delayed cancer treatments, etc.

I most of these cases it took multiple peer to peer reviews. The hospital is on top of this but as you can imagine having a doctor or social worker on the phone for hours per denial is extremely time consuming.

As for the theoretical aspect if something is deemed life threatening or an emergency they do not have to wait. If it is not and the provider does the procedure, test etc they eat the costs because 9 times out of 10 the insurance companies will not give a retro-prior auth. This leads to hundreds of thousands of dollars in lost revenue.

Now I know hospitals inflate prices and some may order unnecessary testing (hence the need for a prior auth) but this is a real issue.

I tell my clients with significant health issues that Original Medicare is usually the best way to go, should they be able to afford a supp or get Medicaid.

It is unfortunate but here in Maine and across the country many hospitals are on the verge of closure or are closing whole floors/departments because they are struggling financially. Spending resources on prior auths definetly can have a big impact.

 

[somarco]

many hospitals are on the verge of closure or are closing whole floors/departments

Maine is not alone . . . same can be said for most, if not all, of the other states.

In Atlanta a couple of hospitals have closed in the last few years . . . mostly small ones in low income neighborhoods. OB departments have closed, same for ER in several local hospitals. Inner city hospitals have Medicaid funded births around 70% of OB admissions. Hospitals cannot survive on Medicaid, nor can they rely on collections after treating someone with a high deductible ($2000+ . . . often $5k to $6k) and the patient skips on the balance.

Uninsured + a high percentage of Medicaid patients also leads to closure of rural hospitals.

I can't see that Obamacare and Medicaid expansion helped much . . . more like rearranging the deck chairs.

 

[KandKsmommy]

Maine is not alone . . . same can be said for most, if not all, of the other states.

In Atlanta a couple of hospitals have closed in the last few years . . . mostly small ones in low income neighborhoods. OB departments have closed, same for ER in several local hospitals. Hospitals cannot survive on Medicaid, nor can they rely on collections after treating someone with a high deductible ($2000+ . . . often $5k to $6k) and the patient skips on the balance.

Uninsured + a high percentage of Medicaid patients also leads to closure of rural hospitals.

I can't see that Obamacare and Medicaid expansion helped much . . . more like rearranging the deck chairs.

Ours closed their OB department last year and in the last year they have let go of 10 primary care providers because they can't afford to keep them. We are in a rural area so they get the rural clinic increased reimbursement from Medicare but they pay so little compared to private insurance that it doesn't make much of a dent.

As for Medicaid expansion and Marketplace it help a bit because we were seeing tons of uninsured but Medicaid's reimbursement is horrible like Medicare and marketplace like you said often has extremely high deductibles.

I was house shopping last year and I seen a lot of liens on properties for medical debt. Annually I think our hospital writes off 1.5 to 2 Million in bad debt.