Prior Authorization Denied

— It's time to flip the system, and make insurers carry the burden of proof

Is it just me or has the process of getting prior authorization for our patients' prescriptions and procedures gotten more onerous?

Over the past few years, our practice has developed amazing systems to help smooth the road for this kind of thing: teams of pharmacists and staff sending over our progress notes, helping fill out forms, checking formularies, to try and make sure our patients get the medicines we prescribe.

And still, in far too many cases, we get a notice back from the insurance company saying the prior authorization has been denied.

I get notices that prior authorizations have been denied because my office failed to respond, when in fact, nobody reached out to us.

I get notices that prior authorizations have been denied because we failed to fill out a form, when I know I filled it out, and I can see in our records that it was faxed to the insurance company and they received it.

I get notices that prior authorizations have been denied because we filled out the form correctly, answered all the right questions, met all the criteria they required, and still, somehow, they decided they weren't going to cover it.

No further explanation provided.

At the end of the day, the bottom line is that they are beholden to their stockholders; the insurance companies have to make a profit, and we doctors are spending all that money they could be turning into profit, trying to get our patients better. And yet, every year we hear about the billions of dollars in profits they are still managing to make.

Maybe we need to figure out a system where they make a little less profit, and the patients they are ostensibly there for -- who are paying their premiums along with their employers, are managing to come up with their co-pays no matter how expensive they are -- should get whatever they need, that we decide they need, to get them to a healthier place.

So maybe it's time we flip this prior authorization process on its head.

We weren't there when it was created, we weren't part of the design of this system, so maybe, collectively, all the healthcare providers who probably know a little better what our patients need, should be the ones deciding what can and can't be provided.

Maybe we can find a way to make them prove there's a reason why we shouldn't prescribe something, rather than the other way around.

If I want to prescribe a medication for my patient's diabetes, high cholesterol, blood pressure, heart failure, obesity, depression, anxiety, and it's FDA approved for these indications, then cover it they should. Or else we should insist they provide us with an alternative that is just as satisfactory to us and the patient.

If they insist on giving the patient a different medication, and the patient won't take it, then what good does it do anybody? The only good medicine is the one that gets into the patient, the one that gets to the site of action, that accomplishes what we want it to.

The economic models of prevention and the control of chronic diseases are solid; we've proved them over and over again.

If I can prevent a patient from getting end-stage renal disease by controlling their hypertension and diabetes, then we as a society, including the insurance companies, should do everything we can, pour every resource, prescribe every medicine to make sure the patient lives their healthiest life, and keep that patient from needing dialysis or a kidney transplant.

We know their obesity is likely going to lead to sleep apnea, which could cause atrial fibrillation or stroke or hypertension, that their obesity is going to lead to osteoarthritis of their knees and an inability to exercise and more weight gain and decreased quality of life and ultimately knee replacement surgery.

The immense costs of prevention and control of chronic illness will undoubtedly lead to massive savings down the line.

Years ago, I remember the insurance companies making this argument: why should they pay for prevention for many years of a patient's life to prevent a statistically possible heart attack or stroke under the auspices of the government when the patient finally gets Medicare?

If we put everybody into the same pool, if we invest in the health of every single member of our society, if we keep everyone healthy and contributing to the benefit of their communities and their families, then in the end, everyone wins.

So yes, they should leave it up to us, the people who, for the most part, are doing the right things for our patients, trying to prevent what we can and control what has already happened or is beyond our control or inevitable.

If we can find a way for the insurance companies to partner with us, to see that this is the right way to do it, the right thing for our patients, then I foresee a world where we're all healthier and happier. And whatever profit is there for the making will be spread around in a much more equitable way.

Then everyone will be better off.