small microscope

Insurance Prior Approval Madness

As I sat at my desk contemplating the topic for the next factoid Friday blog, I considered discussing details of mitochondrial genetics but, due to an extremely frustrating conversation with an insurance company just prior to beginning to write I decided that the mitochondrial patient population would likely be better served if I relayed details in regards to the battleground we physicians face on a day-to-day basis dealing with insurance companies over coverage of various services and medications for patients and how that impacts their care.

Although issues with insurance companies impact all aspects of care, the focus of this blog will be on prior approvals (PA) specifically, how the demand for obtaining them has exploded overwhelming physician practices leading to attrition and reduced coverage of requested medications and services. Simply stated the explosion of PAs is unsustainable for physicians and, as such, patients will not get appropriate care.

Several years ago, after implementation of some of the changes in healthcare, we saw a palpable increase in obstructionary behavior from insurance companies requesting and demanding prior approvals for far more medications and services including those previously covered for a given patient. This uptick in PA demands has become unsustainable from a medical practice perspective.

For those of you unfamiliar with this process, essentially the insurance company states that they will not provide financial coverage for a given medication or service unless the physician goes through a complicated process of providing information on a given patient and justifies to the satisfaction of the insurance company why the patient should receive the recommended service or treatment.

This prior approval process typically requires either a phone call lasting15 to 20 minutes in duration, completion of reams of nonsensical paperwork, or some other equally time-consuming endeavor providing information that the insurance company already has in their computer systems.  Once completed, the insurance company will then undertake its "review" of the data and come to some determination as to whether or not they will cover the requested item. As you can imagine the answer is typically "no" regardless of the hoops one has jumped through to secure approval.

In theory, in a system that perhaps sees some excessive and unnecessary interventions, the practice could be heralded as a part of a checks and balance system to ensure good usage of healthcare dollars. However, in actuality, this seems to be merely a process enacted to prevent provision of care coverage.

If, upon calling for a prior approval I was able to undertake an intelligent conversation and discussion regarding the pros and cons of my suggested therapeutics with consideration of other alternatives that may perhaps be less costly or linked to better outcomes this might prove useful to patients.  But, of course, that does not happen nor does it seem to be the intent of the exchange.  I believe that it is a process enacted to prevent provision of care coverage at the expense of everyone involved in healthcare except for the insurance companies.

So instead of a constructive conversation aimed at improvement of patient care, the dialogue typically unravels and proves to be a useless and a monumental waste of time.  In the case today, the insurance representative demanded that I provide her with the ICD 10 code for mitochondrial disease as part of her inquiry into whether or not my patient should receive coverage for my recommended therapeutic. If this individual is going to be determining whether or not one of my patients should be treated as recommended by an internationally known expert with 25 years' experience she should, at the very least, be familiar with the ICD 10 code involved.

Should someone who does not even know the ICD 10 code for mitochondrial disease be the person responsible for determining whether my patient with crushing, overwhelming fatigue that keeps her bedridden most days should or should get coverage for an increase in a medication previously shown to improve this problem? Of course not, but it happens every day.

These clerical insurance reps who have no medical training use woefully inadequate algorithms that I suspect have no current data on these rare diseases to negate the care I have determined is required for my patient.Why then did I go to medical school,  complete residency and sub specialty fellowship training and take boards if I am overridden by a unqualified non-medical insurance rep and a poorly constructed computer program?

While everyone who has dealt and struggled with insurance in the healthcare system recognizes that it is extremely obstructionary process little is done about it. We complain, we moan, but, in the end, we shrug our shoulders and move on to the next battle on our plates. Perhaps that is all some of us can do and insurance companies may count on it.

However, in my opinion, this issue is going to only get progressively worse and, as patients and physicians we need to understand that and begin to formulate  a plan to regain control of healthcare.

The first question, of course, is why is this happening? It is a very simple explanation. Money. When insurance companies and Medicaid and Medicare were required to provide expanded coverage to millions of previously uninsured individuals, they quickly recognized that their profit margins would be decimated if they did not implement other measures to protect their bottom line. So, in response to these changes, they and commercial insurance companies instituted a widespread policy whereby almost everything is denied. In our experience, there has been at least a 50% uptick in denials over the last several years now reaching an unsustainable level.

Medicaid and Medicare patients fair far worse. Because reimbursement to physicians is unrealistic, Medicaid and Medicare providers are now few and far between. While most practices could previously absorb the income loss associated with provision of care to this patient population, a swell in patient numbers with an even poorer reimbursement rate has led to the closure of a number of practices and the refusal of many others to accept patients with Medicaid or Medicare. In addition, these government based insurance plans do not cover much of the needed testing and many of the interventions required for complex patients such as those with mitochondrial disease. As such, PAs are not even a consideration for this patient population and care is simply limited.

But what do we do about the situation and how can we improve and fight for the care of complex patients?

While there are no simple solutions, patients and families can fight back by demanding reforms to the process. The following are several suggestions:

  • Contact your State Insurance Commissioner's office to report egregious insurance company behavior.
  • Create websites or blogs where patients can report and discuss problems with various insurance companies which can lead to consumer pressure to modify discriminatory practices against complex care patients or face massive policy cancellations by disenfranchised customers.
  • Hold insurance companies accountable. Demand from the insurance company the exact reason why a PA was issued, how often are PAs issued over the same reason, and how often are similar PAs approved by them.
  • Push for changes in insurance with your local, state, and federal representatives. One suggestion to stem unnecessary obstructions caused by insurance is to force insurance companies to reimburse for the work that they create by their demands. Currently they make their demands at the expense of everyone else as they will not reimburse for the time to perform a PA, or to submit letters of medical necessity, or any of the other myriad demands they inflict into the process of healthcare. For example if they had to pay for the MD to spend 15 minutes over a PA, we suspect that there would be fewer PAs issued and only when warranted.

In summary, obstructionary practices by commercial insurers and poor coverage by government policies are preventing necessary care, impacting complex patients most given their need for more interventions. However, we as a community are not helpless. We have a strong voice and can hold them accountable, after all we are the customers of the insurance company and we pay their salaries. It is about time they start to treat us as customers or we can & will take our business elsewhere.


Fran Kendall, M.D.

This post is not meant to be a recommendation or a substitute for professional advice and services rendered by qualified doctors, allied medical personnel, and other professional services. The responsibility for any use of this information, or for proper medical treatment, rests with you.