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daup h i n c m s .o
.o rg

spite of the fact that we were doing the right thing
(by lowering his dosage) - getting him off opioids
- pre-certs would still be coming."
Stanziano said he was never given a clear answer
as to why his medication decrease required a prior
authorization.

Insurance PrIor
auth Delays
harm PatIents
By JEFF WIRICK
Pennsylvania Medical Society

"You could talk to two different people (at the
insurance company) in the same day and get two
different answers," he said. "Explain to me the logic
- why are you denying it when we were trying to
reduce (the medication)? Does it make sense to you?"
"Are you trying to cut costs, or are you trying to
cut lives?" Stanziano continued. "I can understand
trying to cut costs, but put them in my situation.
Let them be on the medication for a certain period
of time, and not be able to refill it, and have to go
through what I went through."

Prior Auths On The Rise

Physicians have seen a dramatic rise in prior authorizations over the past few years for a variety
nsurance companies say they use prior authorization to prevent physicians from prescribing too of treatments and medications:
much medication or ordering too many tests. But physicians say the use of prior auth has grown
out of control - and few stories illustrate it better than that of Joe Stanziano.
86 percent of respondents to a Medical
Group Management Association survey said
Stanziano, who currently resides in Montgomery County (Pa.), owned a bakery in New Jersey. that they experienced an increase in the numTen years of carrying heavy bags of flour and working 18-hour days took a toll on his back. Stanziano ber of prior authorizations over the past year.
had just undergone his fourth back surgery in five years and was taking pain medication to help with Medical practices average 37 prior authorizations
his recovery. Things were progressing well enough for Stanziano to begin taking a smaller dose of per week, per physician (taking up an average of 16
the pain medication - a process known as tapering that could eventually allow him to wean off the hours per physician), according to a survey from
medication altogether.
the American Medical Association.

The problem is, Stanziano's insurance company denied payment of the lower dosage that his
A few years ago, "If a narcotic that we're prescribing
neurologist prescribed. Hours turned into days and Stanziano continued to wait for his insurance was thought to be at a very high dose, you might
company's approval.
have a pre-cert," Dr. Skubick said. "But the prior
auth would last 6-12 months and it might occur
When his current allotment of pain medicine ran out, the withdrawal symptoms began.
occasionally. Now, over the last few years or so, fueled
by the opioid crisis, we're running into pre-certs
"Cold sweats. Shaking. You don't have control," Stanziano described.
whenever a change is made to the medication."
This wasn't a one-time mistake by his insurance company. Stanziano's neurologist prescribed a lower
The delays are proving costly to patients. Here are
dose of pain medication five times. It was denied five times for up to a week before it was approved. just two more examples: Pittsburgh's Jeff Duncan
waited eight months for approval on an in-lab sleep
As the delays grew longer and withdrawals continued, Stanziano opted to buy the medication out study that he needed in order to receive treatment
of own pocket. Each pill cost $60.
for his severe sleep disorder.
"One could imagine a reason for (denying it) if we're increasing the medication, but in Joe's case we
were gradually decreasing the medication," said Daniel Skubick, MD, Stanziano's neurologist. "In

Continued on page 26

Central PA Medicine Fall 2017 25

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