Industry Voices—Prior authorizations frustrate physicians. In radiology, denials can be life-threatening

By Michael Sculley Sep 4, 2018 12:14pm

Speak with just about any physician about prior authorization and you’ll quickly hear their frustration.

Speak to a physician about radiology denials, and that frustration will reach a pain level that’s hard to bear.

After all, CTs and MRIs are not ordered for minor ailments—they’re sophisticated diagnostic tools aimed at uncovering causes for serious conditions. And when they’re denied by insurers, the consequences can be life-threatening.

Take the experience of oncologist Jennifer Lycette, M.D., who blogged about the problem in a post picked up by Doximity. She asks why she bothers to renew her medical oncology and hematology board certifications if “insurance companies can dictate what kinds of tests we, as physicians, can order?”

When you read the examples Lycette gives of recent denials, you begin to understand. In one instance, she requested an MRI of the brain for a patient with a history of malignancy who was displaying new concerning neurological symptoms. Unfortunately, the payer approved the MRI without gadolinium contrast, which would make it nearly impossible for the radiologist to evaluate the brain and meninges.

In another instance, a payer denied prior authorization of a repeat ultrasound, saying that they only authorize repeat ultrasounds for lower extremity deep venous thrombosis (DVT) under specific circumstances. The problem was that Lycette had requested the ultrasound to make sure an anticoagulation treatment had been effective against an upper extremity DVT before a surgeon removed a portacath.

In a third case, Lycette had to appeal the denial of reimbursement for a CT scan she ordered to make sure there was not metastatic disease in a cancer patient before recommending treatment. She was told that the payer had subcontracted the patient’s care to a subsidiary. The subsidiary said the parent insurance company was responsible for authorization decisions. “After one week of repeated calls to both companies, we still did not have an answer,” wrote Lysette. “We had to delay the start of chemotherapy.”

One reason payers are targeting scans is their desire to drive these tests away from hospitals and toward freestanding outpatient facilities, which tend to charge less for the facility fee than do hospitals. For instance, Anthem Blue Cross Blue Shield rolled out a new imaging policy in 13 states that steers individuals away from hospital-based imaging services and toward less costly, freestanding imaging centers.

In some cases, these types of payer policies do not raise medical issues; the scan can be done with the same results at a lower price. However, patients who live in remote areas may find that the closest freestanding radiology facility is 75 or 100 miles away. If a patient has a disability or is low income, the prospect of that trip may lead the patient to decide not to get the test.

Patients with chronic diseases can also be greatly affected by these policies, as indicated on Your GPS Doc. For example, cancer survivors often get scans every three or six months to ensure the cancer is in remission. Being forced to move from the hospital where they have had their scans done to a freestanding facility can be tricky. For instance, it carries the risk that the scan could be read by a radiologist with less extensive experience with their type of cancer. And getting a copy of a scan to the patient’s specialist may involve the patient physically carrying it there if the sites’ electronic systems are not compatible.

As Lycette puts it, “Each denial represents potential delay in care for the patient and redundant work for the physician—work that expands exponentially from the initial time taken to submit a carefully-worded request (in the futile hope that one might receive an approval on the first try). The incredulous laughter at the absurdity of the denials turns quickly to lamentation as my inbox fills each week with more and more denials of preauthorization for reimbursement, which must be appealed.”

A move toward standardization is underway.

Six leading health industry groups, including the American Medical Association (AMA), the Medical Group Management Association and America’s Health Insurance Plans, have joined in a commitment to improve prior authorization processes. The AMA is asking for clinical validity by insurance payers during utilization management, and that approval or disapproval of a requested diagnostic be based on up-to-date clinical criteria rather than on algorithms or a step therapy (fail first) basis.

Michael Sculley is vice president of digital marketing at PracticeSuite.com. He has covered the healthcare technology sector since 2005 and is the editor of The Smart Medical Practice blog for the company since 2012. Disclosure: PracticeSuite sells software for electronic prior authorizations.

Patient Safety Physician Practice Prior Authorization Radiology American Medical Association America’s Health Insurance Plans (AHIP) Elevance Health (Anthem) Doximity Medical Group Management Association Hospitals