Linda Girgis, MD

There is nothing more frustrating to physicians than knowing a patient needs a certain diagnostic test or medication and having them not be able to get it because their health insurance company won’t cover it. All too often, many services require prior-authorization (PA).

It wouldn’t be so bad if the insurance companies made the guidelines they use to make these determinations readily apparent to those practicing medicine. However, these guidelines are created by the insurance company (with a main goal being cost containment rather than evidence-based medicine), unavailable to treating clinicians, and often they use decades-old recommendations. We are often left to predict the insurance company’s decision.

Many of us feel that it is like playing an epic game where we try to give our best care to our patients, while the insurance companies deny as many tests as possible to increase their profits. The loser of this game is not the one who was able to get the least amount of services covered or earned the least money. Rather, it is the patient: delayed diagnoses/treatment, denied tests, forced to use less effective medications based on formularies developed by insurance companies using their own guidelines, and footing increased costs.

How can this prior-authorization game be played for better odds of winning?

Ways to play the prior authorization game

While these tips may help get some services covered, they often still do not work. The insurance companies hold a lot of power over these medical decisions. The most important thing is to keep fighting the ones we don’t medically agree with. The day we all quit the battle is the day we lose the game and big insurance companies win and determine medical care. We must remain diligent in our fight for optimal clinical outcomes in all and each of our patients.

Articles

Prior authorizations are a pain for physicians. Here are a few things you can do to improve your odds of winning.

 features contributions from members of the medical community. The expressed opinions are that of the writers and do not necessarily reflect the opinions of 

Physicians are increasingly being squished. As 

 rates decrease or remain stagnant, many people think the solution is to see more 

. Unfortunately, this just doesn’t work in medicine. Those who tend to see 

 seem to also be the same ones who think rushing patients in and out of the office to increase numbers is the answer.

Here are six reasons why seeing more patients is not the solution:

Patients are living longer with more chronic and complicated diseases.

They need more time with physicians and other healthcare providers than ever before. Patients usually have more diseases to monitor and potential complications to watch out for. Additionally, patients are often on more medications, and physicians need more time to discuss potential side effects and interactions. Shortening visits even further means more patients leave the exam room with questions unanswered and conditions undetected. This takes more time down the road. And it sets up the stage for missed diagnoses and unnecessary complications.

When we see more patients, we have less time to document, and we are already struggling against an ever-increasing charting burden. We need to report certain metrics to meet MIPS/

 requirements. We can’t see more patients and record more data at the same time.

 before they come to see us. This does not save time in most cases. Rather, patients come in with many questions that need answers. If we address their concerns up front, they don’t need to call back with additional questions that weren’t answered at the time of their visit or return to have us look at something that was left unexamined.

More patients equal less time to answer all of patients’ concerns in one visit.

Some doctors now limit the number of problems patients can discuss at one visit. I am a family doctor, and often patients may have many disparate concerns that end up being related. For example, a patient may be concerned about why she is so tired and why her legs are swelling. Those are two concerns. However, if we listen to all her concerns, she may also tell us that her hair is falling out and she has trouble swallowing. These added concerns lead me to make the diagnosis of hypothyroidism.

don’t spend enough time with them or listen to all their concerns

, they are not happy. They come to use and are worried about a problem, stressed out about life events or just wanting to make the best decisions to stay healthy. We can do much to ease that - if we have time.

When we rush patients in and out to try to increase numbers, we are not able to comfort our patients. Again, this may lead to follow-up calls. Or worse, the patient 

 about us online or looks for another doctor who can give them 5 extra minutes, both of which can cause our profits to decrease. While we can’t make every patient happy, we should do our best to listen and try to help them find answers.

Everyone is talking about the high degree of 

 among physicians. Most of us are already operating at full steam. Trying to pile more on us is only going to make this problem worse. When we see more patients, we often are left with piles of paperwork to complete after-hours due to the endless load of increasing documentation requirements.

Doctors are human. We need rest, too. We have families, and they need us too. Unless we are allowed to take care or ourselves and our loved ones, our health will suffer. An ailing doctor is not an effective one.

While many in the C-suite think seeing more patients can boost 

 and profits, they fail to see the reality those on the frontlines face every day. Pushing more patients through a dysfunctional healthcare system is not helping anyone, patients or healthcare providers alike. Executives at organizations may see an initial boon to the bottom lines, but over time they are going to burn their resources (i.e., doctors) to the ground. Then they will be left with a crowd of patients in the waiting room and no one left to take care of them.

If we want to improve physician efficiency and productivity, we need to fix our 

, MD, is a family physician in private practice in South River, N.J. She is also the author of six books, the editor-In-chief of 

 and a widely-published author. You can find more of her work at 

Though traditional fee-for-service reimbursement is tied to volume, quality patient care can’t be increased by simply adding more appointments. 

Why seeing more patients doesn’t equal greater productivity

Interoperability was touted as the promise of electronic health records (EHRs). The vision was to create systems that could communicate with each other, making patient records available wherever and whenever they may are treated.  While some systems talk with each other, the truth is that we do not yet have wide-scale interoperability in the healthcare system.

Integration is needed in order for disparate systems to share data. Different vendors need to work together to make interoperability a reality. And, for the most part, EHR vendors are not willing to do this. They have little incentive to build a bridge to another company’s software. After all, they’re a business, and they’d rather sell their own products than share with their competitors.

As a result, providers are stuck in the middle, and that puts patient care at a halt - and a disadvantage. Here are five ways the failed promise of interoperability interferes with daily practice.

In the past, labs and radiology facilities would fax or mail results to physicians’ offices. Today, some have the capability to integrate with certain systems to directly upload data into the EHR. Unfortunately, many do not.

The results still get faxed and mailed to us. Then we need to scan, download, and upload them into the patients’ charts. This clearly involves extra steps and extra time, none of which we’re paid for but need to do for proper documentation and the best patient care.

Interoperability makes it harder to get information that isn’t shared but should be. One of our local hospitals is supposed to be integrated with our system. But sometimes, the results don’t appear in our EHR. We then have to call and request the results. The clerk then argues we already have access to it.

When we finally convince him/her that we don’t have it, the clerk will fax it over, maybe within 15 minutes, maybe within 15 hours. Patients get upset waiting that long for the fax to come, and we’re left waiting until it does.

When systems stop communicating with each other, no one is to blame. One of our local labs is integrated with our EHR but for two weeks, none of the lab results appeared in our EHR. We called the lab and after a 30-minute hold, we were told it was the fault of our EHR software. After another 30-minute hold and an hour and a half phone conversation with our EHR vendor, we were told the fault was with the lab software.

We were going back and forth between both companies for several days. In the meantime, we had to have all the results faxed over, scanned in, downloaded and then uploaded. Once the integration suddenly started working again, we then had double lab entries in all those charts from the previous two weeks, meaning we had to spend even more time reviewing and removing those duplicate results.

Software vendors don’t all do their updates at the same time. When the system is down for one system to update, the others are still going. Then those are down at other times, creating a never-ending cycle of updates.

When a system is down, it doesn’t integrate with the others. In other words, we need to repeat the familiar yet frustrating process of faxing, scanning, downloading and uploading the data.

Keystoke errors in data input can lead to prolonged searches. For example, if my practice doesn’t enter the patient’s middle initial but the pharmacy does, that creates a data mismatch, meaning the prescription will not be recorded in the patient’s chart. Sometimes a simple search will resolve the issue, but it is often more complicated.

When the patient comes for the follow-up appointment and the results are not in the EHR, we end up calling to request the results (maybe after a 15 to 20 minute hold) and they are then faxed over. Those records then they have to - you guessed it - be scanned, downloaded and uploaded into our EHR system.

Where no bridge exists, a website may offer a connection. Many third-party companies now allow providers to access online portals to view results or records. This can be a great workaround if you are dealing with only one or two sites, but it becomes a very complex process when there are six or seven sites to look up, access, download and upload results.

Interoperability is a great idea, but we are still far from achieving it. And, in my opinion, I doubt we ever will. In the meantime, the lack of interoperability place burdens and waste time from a physician’s daily practice.

EHR interoperability is a great idea in theory, but the reality leaves much to be desired.

5 ways interoperability fails physicians

Getting paid for procedures continues to become more complicated. Many doctors are adding new procedures to their offerings that patients want and can benefit from, such as Botox to treat migraine headaches, dermal fillers for aesthetic purposes, laser therapies for scar reduction, stem cell and platelet rich plasma (PRP) injections for musculoskeletal disorders, genetic testing, and many more. But insurance companies often won’t pay for them. 

How can physicians collect on services not covered by third parties?

Before anything is done, inform the patient how much they will need to pay and why. If a service is one that needs to be done more than once, or has that potential, let the patient know first. The patient will be upset paying out-of-pocket only to learn that there will be further expenses in the future. 

Ask the patient to sign a statement that they understand that they are responsible for the expenses. 

In my practice, if a patient receives a bill, they often claim they had no idea they were responsible for any payments. All we have to do is show them their signature and they cannot argue.

The simplest way to get paid is to ask for it before the service is provided. If a patient wants Botox, for example, they should pay for it prior to the injections. It is always harder to collect after the procedure is done. You can’t get that vial of Botox back even though you’ve already paid for it. That is just lost revenue. 

Participate in care credit of other similar programs.

Physicians can sign up for a program that allows patients to make payment plans rather than paying the whole amount at once. While this may not make sense for a procedure that is less costly, it may be the only way a patient can afford more expensive ones. This is often used by orthodontists when the cost for children’s braces is in the thousands of dollars. 

If there are alternative options available, share them with the patient and discuss the pros or cons of each. For example, a patient with a torn meniscus ma benefit from physical therapy and non-steroidal anti-inflammatories, which insurance will cover. However, some options not covered by insurance, such as PRP and stem cell injections, may have greater efficacy and be longer acting. When a patient is aware of everything that is available, they may opt for the therapy that they have to pay for themselves. If you don’t discuss all the alternatives, they may think you are just trying to sell them something. 

Make sure your staff knows what is covered and what isn’t.

A patient doesn’t want to schedule an appointment and be told the insurance will pay for it and then be disappointed. Also, the patient will get angry if they have the procedure done thinking it was a covered service only to get a bill later because someone made a mistake.

In our current healthcare system, we need to treat patients as decision makers, and the only way they can make informed choices is if they have all the facts. This does not only apply to the medical knowledge but cost factors as well. 

Six tips that can help physicians collect on services not covered by third parties.