Originally Posted by
Hmac
Yes. Various operations, particularly the advanced MIS operations and revisions that I do, routinely require pre-authorization and are routinely denied. That in turn leads to time-consuming wrestling with appeals to the insurance company while the patient is in limbo, and often suffering to some degree. At least a couple of times a week, I have to take time out of my day to talk on the phone with some Family Practitioner insurance company medical director that hasn't practiced medicine in years since he/she took that 9-5 desk job and review for him/her the current literature (because I actually read the current literature) that supports an obvious assertion as to why that particular patient needs that particular operation.
Furthermore, they aren't stopping at denying pre-authorization for surgical procedures. A couple of days ago, I got this email, cut and pasted here, from our Radiology director.
So...you come into my office with significant lower abdominal pain increasing over three days. I suspect diverticulitis but need a CT scan to confirm that diagnosis and determine whether or not it has perforated and an abscess has formed that needs to drained (which, by the way, will require another pre-authorization). Or, whether or not I need to take you to the operating room within the next few hours. Sorry...you'll have to wait 5-7 days for pre-authorization from your insurance company (not including the weekend) OR I can send you over to the ER. You'll sit over there for awhile in the waiting room. They'll evaluate you, repeat the labs I already drew in the office, then order the CT scan, and then call me for an ER consult. They'll charge you a bunch of money for the ER visit, you'll have to cough up another co-pay, AND you'll have to cover that rather breathtaking component of your insurance deductible. And by the way, I'll have to charge you for an ER consultation in addition to the office visit I just charged you for earlier that day while you were in my office. Think about what that costs...not just the extra ER visit but the fact that we actually have a "Pre-Authorization Department". Several people, all getting a salary and benefits, whose sole job it is to help a patient wade through and stand in line while the health care rationing process plays itself out.
Additionally, what if it's not a "true emergency" that warrants a trip to the ER? What if you're just in pain, but your labs and vitals are stable? Not life-threatening, just painful? I don't know exactly what's going on in your body...how do I treat you? Do I give you pain medication to try to keep you comfortable while we wait for the CT scan to be approved? No, I can't do that....we have an "opioid crisis" here in the US, so I can't give you pain medication. So....sorry. Good luck with all that...I'll see you back in 5-7 days (not including weekends) after we have the CT scan. If, or when, you get worse and it becomes a true emergency, then you can hit the ER and we can begin the process that I tried to start 5-7 days ago.
This is just a rather routine example of the "cost containment protocols":rolleyes: that insurance companies are increasingly implementing. It's not just a nuisance, it's time-consuming, prevents me from providing good patient care, and detracts from my ability to be productive. The solution? I don't have time to wade through the pre-authorization process so we just hire a bunch of people to do all that nuisance work. Yes, it's expensive but it actually saves us money if it keeps the doctors productive and providing patient care. But seriously...think about the cost of hiring all those administrative people. Who do you think, in the end, is paying for that?
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