Berks County Medical Society Medical Record Summer 2017 - 23

You have no way of knowing ahead of time what the insurance
company will approve because their policies are not made available
to you. Furthermore, even if you did have that policy made
available to you, those policies that govern their decisions will
continue to evolve. They have to. The scientific base of medicine
continues to march on. The outcome of this is that you don't know
"what the rules are," and it's hard to envision a scenario where you
ever will.
And this is why more and more medical interventions require
pre-authorization. The health care provider submits the prescription
of the physician or other health care provider, and the insurance
company gives an answer of whether or not the prescription is
medically necessary. The bright side is that patients are much
less likely to get a large bill for something not approved, and the
providers know ahead of time what the insurance company is likely
to pay. But there is a dark side. It adds a layer of cost, hassle, and
frustration to the ordering physician. Surprisingly, pre-authorization
does not even guarantee any payment will be made. The insurance
company still retains the right to not pay for the service! As the
pre-authorization process takes over every nook and cranny of
medicine, an army of billing specialists have been employed to
shepherd providers, and physicians are spending more and more
and more time devoted to filling out forms, waiting on hold to
talk to a reviewer, and then talking to reviewers why they want
a patient to have a certain drug or procedure. The vast majority
of pre-authorizations are approved, largely because physicians are
fairly good at prescribing appropriate interventions. So, in most
cases, it is a waste of effort that adds value to no one. Even in
cases where the prescription is not approved, it is rarely because
the recommendation of the physician was wrong. It is almost
always because there was another cheaper alternative the insurance
company demands must be done first, irregardless of whether or not
that makes the most sense for that individual patient.
PAMED is not sitting idly by while this carries on. PAMED
supports HB 1293 , a bill introduced 4/26/2017 that streamlines the
prior authorization process with insurance plans. This will codify
limits on what obstacles insurance companies can put in place for
the approval of medical prescriptions and orders. Even if there are
unintended consequences, and almost all legislation does, for most
of us in the house of medicine, it will provide some much needed
relief if passed. It is not a given this will pass as it will likely be
opposed by the insurance companies, but if physicians and patients
call their legislators, it will, as this issue has enormous bipartisan
support.
However, this issue shouldn't be about demonizing insurance
companies. I voluntarily remain in the world of health insurance,
and so will most of you. Furthermore, PAMED represents all
physicians, including those working for the insurance industry as
policy makers and reviewers. Most of them truly want patients
to get appropriate cost effective care, and they are frustrated by
the process as well. By working together and advocating for our
patients, we can make this mess better. So stay engaged!
1

About the Aurthor:
Dr. Mackley is a Radiation Oncologist at the Penn State
Cancer Institute and Professor of Radiology, Medicine, and
Pediatrics in the Penn State College of Medicine. As the
5th District Trustee on the PAMED Board, he represents
physicians of this county.

https://www.pamedsoc.org/Pages/Advocate%20Specific/PAMED-Priorities.aspx
SUMMER 2017

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Table of Contents for the Digital Edition of Berks County Medical Society Medical Record Summer 2017

Berks County Medical Society Medical Record Summer 2017 - 1
Berks County Medical Society Medical Record Summer 2017 - 2
Berks County Medical Society Medical Record Summer 2017 - 3
Berks County Medical Society Medical Record Summer 2017 - 4
Berks County Medical Society Medical Record Summer 2017 - 5
Berks County Medical Society Medical Record Summer 2017 - 6
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