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?
- Whoever does the PA needs to have the progress notes in front of them. They will be asked clinical data and it should be at their fingertips.
- Know what needs to be documented in the chart. For example, I had a patient with knee pain who I suspected a torn ligament in the knee. When talking to the rep to get prior-authorization for an MRI, I told her the patient had a positive drawer sign. She never heard of this before and because I didn’t record the results of the Lachman test in the note, she could not approve the MRI. She didn’t know what this test was (I asked) either, but it was a checkmark on her decision tree. I record them all.
- Learn what is needed to get an approval. One example is that with certain insurance companies, every time I order an MRI of the lower back, they want the patient to have had a plain X-ray first. Why? There is no evidence that X-rays are a good test to diagnose back problems. In fact, if I am looking for a herniated disc, a plain X-ray will not show it but rather an MRI is needed. I know this but sometimes the only way to get the patient to get the test is to do it anyway.
- Don’t give up. If a test is denied, appeal it and keep appealing it. I find that this is not often successful but sometimes is. Plus, the insurance company should not be given an easy pass for refusing to cover something a patient needs.
- Get the patient involved. They should be contacting their insurance company as well. They will be talking to member services and sometimes they find a sympathetic ear who helps them get coverage or reveals the holy grail of coverage determination to them. They are often successful when we are not.
- Remember human resources. If a patient works at a company that has a HR department, have the patient get them involved. Insurance companies do not want to lose any covered lives so if they find a company is unhappy with the services provided, this can be a very effective weapon.
- Ask for the medical director of the insurance company. Most of them were practicing medicine at some point and understand our struggles on the frontlines. If we present our medical reasoning with them, they often are able to authorize a test. Not always.
- Talk to your provider rep at the insurance company. They often know the right person to talk to that may help you get the service covered.
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.