LCHM Winter18 - 25
L C M E D S O C .O R G
"One could imagine a reason for (denying "But the prior auth would last 6-12 months
it) if we're increasing the medication, but and it might occur occasionally. Now, over
in Joe's case we were gradually decreasing the last few years or so, fueled by the opioid
the medication," said Daniel Skubick, MD, crisis, we're running into pre-certs whenever
Stanziano's neurologist. "In spite of the fact that a change is made to the medication."
we were doing the right thing (by lowering his
dosage) - getting him off opioids - pre-certs
The delays are proving costly to patients.
would still be coming."
Here are just two more examples:
Stanziano said he was never given a clear
answer as to why his medication decrease
required a prior authorization.
Pittsburgh's Jeff Duncan waited eight months
for approval on an in-lab sleep study that he
needed in order to receive treatment for his
severe sleep disorder.
"You could talk to two different people (at
the insurance company) in the same day and
"What if I would have died with this?" he said.
get two different answers," he said. "Explain "Personally, I'm just irritated that the insurance
to me the logic - why are you denying it when companies have so much power over doctors
we were trying to reduce (the medication)? trying to get their patients what they need."
Does it make sense to you?
Pittsburgh's Kristen O'Toole experienced
"Are you trying to cut costs, or are you delays in getting an MRI for her back pain.
trying to cut lives?" Stanziano continued. "I The weeks' long wait allowed her undiagnosed
can understand trying to cut costs, but put multiple sclerosis to progress, and she is now
them in my situation. Let them be on the in a wheelchair.
medication for a certain period of time, and
not be able to refill it, and have to go through
"If I had gotten the MRI earlier and started
what I went through."
on the infusions, I really believe it could have
kept some of these symptoms at bay," O'Toole
PRIOR AUTHS ON THE RISE
said. "Maybe I would have never ended up
Physicians have seen a dramatic rise in prior in a wheelchair."
authorizations over the past few years for a
variety of treatments and medications:
"The doctor knows there's a problem here,"
O'Toole added. "There's something going on.
86 percent of respondents to a Medical And how is he going to know before he gets
Group Management Association survey said the data from the MRI?"
that they experienced an increase in the number
of prior authorizations over the past year.
Dr. Skubick said his biggest frustration
with the rise of prior authorizations is that it
Medical practices average 37 prior au- takes the clinical decision-making out of the
thorizations per week, per physician (taking hands of physicians.
up an average of 16 hours per physician),
according to a survey from the American
"I think it is incredible that the insurance
company would think that a person who has
practiced neurology for 35, 40 years doesn't
A few years ago, "If a narcotic that we're pre- know more than somebody on the other end
scribing was thought to be at a very high dose, without seeing the patient," he said. "I've
you might have a pre-cert," Dr. Skubick said. never had a pre-cert denied for any diagnostic
study when I'm able to talk to a colleague
that is a neurologist.
"But I'm talking to people (at the insurance
companies) who are not even doctors some
of the time. And sometimes when you do
get a doctor, you're getting an internist or
a gynecologist - what do they know about
neurology? What do they know about the
subtleties about whether an MRI is necessary?"
PHYSICIANS MUST BE PART OF THE
Oncologist Rick Boulay, MD, wrote a
recent blog for KevinMD: "Most patients are
unaware of this, but your physician is likely
your biggest advocate when it comes to getting
your care covered" from prior auth.
Similarly, physicians need to step up to support new legislation in Pennsylvania that aims
to decrease patient wait times from prior auth.
House Bill 1293, introduced by Rep.
Marguerite Quinn (R-Bucks), would:
Increase transparency and consistency in
prior authorization criteria
Establish standards for and reduce the
overuse of prior authorization
Lessen manual processes and enhance
the electronic exchange of information
Develop a standard prior
The Pennsylvania Medical Society and
its coalition of 50+ physician and patient
advocacy organizations support HB 1293. But
this legislation will only move with a strong
grassroots effort from physicians, medical
office personnel, and patients.
SEE HOW YOU CAN GET INVOLVED BY GOING TO THE PAMED WEBSITE,
WINTER 2018 | Lehigh County Health & Medicine 25