STATEMENT: Stunning investigation in California raises questions in Pennsylvania about prior authorization of health insurers

Last Updated: Feb 20, 2018

The following is a statement from Theodore Christopher, MD, president of the Pennsylvania Medical Society. Dr. Christopher is also professor and chairman of the Department of Emergency Medicine at the Sidney Kimmel Medical College of Thomas Jefferson University in Philadelphia. He reacts to recent reports related to Aetna and prior authorization.

(Harrisburg, Pa. – 2/20/18) "If the health insurer is making decisions to deny coverage without a physician actually ever reviewing medical records, that's of significant concern to me as insurance commissioner in California -- and potentially a violation of law.”

Theodore-Christopher-MDThat’s what California Insurance Commissioner Dave Jones told CNN recently after learning about a former medical director for Aetna who admitted under oath he never looked at patients' records when deciding whether to approve or deny care.

If it’s happening in California, where else is it happening? Since Aetna offers health insurance to Pennsylvanians, and covers state employees, it’s a question our insurance commissioner and legislators should be asking.

The entire problem stems from what is called “prior authorization.” That’s a process all health insurers follow before approving care recommended to a patient by their physician.   While efforts to contain costs is a noble endeavor, continually questioning a physician’s recommended treatment leaves patients waiting in the lurch until an insurer deems it to be appropriate.  What’s more alarming is when an insurer disregards a physicians’ clinical judgement and flatly denies coverage, leaving patients feeling vulnerable and angering already frustrated physicians. 

For example, the Pennsylvania Medical Society is aware of patients who suffered delays from their insurance coverage for care recommended by their physician. Only after hours on the phone by both patients and their physicians were denials reversed.

There’s the story of Middletown, Pa., teenager Zachary Souders who was caught in the middle of a confusing and convoluted prior authorization process that caused him to unnecessarily suffer months of pain due to juvenile idiopathic arthritis. It took his family and his physician months to convince his insurer to approve coverage of a treatment that ultimately brought relief.

And let’s not forget about Kristen O'Toole of Pittsburgh whose undiagnosed MS progressed because of prior authorization delays for an MRI.

Patients deserve timely and appropriate care. Unfortunately, that doesn’t always happen.

And, sadly, a bill that could help solve this problem has been stalled in committee.  Pennsylvania House Bill 1293 was introduced in May 2017 by Rep. Marguerite Quinn (R-Bucks) and currently sits in the House Insurance Committee. Among other important reforms, House Bill 1293 improves transparency and gives health insurers a deadline to make a decision.

It’s important that this bill moves to give other patients a fighting chance to receive timely care. They don’t need to suffer like Zachary Souders and Kristen O’Toole did.

Patients who find themselves battling health insurers over approval of care need to do two things.

First, they should make an official complaint to the Pennsylvania Department of Insurance. That can be done through a website set up by the insurance department at http://www.insurance.pa.gov/Consumers/File%20a%20Complaint/Pages/default.aspx or by calling 1-877-881-6388.

And, second, they should inform their State Representative and urge them to support House Bill 1293.

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The Pennsylvania Medical Society was founded in 1848. To learn more about PAMED, visit its web site at www.pamedsoc.org or follow on Twitter @PAMEDSociety. Members of the media are encouraged to follow Chuck Moran on Twitter @ChuckMoran7. Dr. Christopher can be followed on Twitter via @PAMEDPrez.

 

 

5 comments

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  1. Anthony Crofton May | Feb 23, 2018

    I agree with Dr. Messmer. The pending bill would simply standardize forms and processes for pre-authorizations. While this can enable office staff to become more accustomed to the process and compel decision making in a more timely manner it would not address the overall burden of pre-authorizations and de facto gives credibility to the whole practice which has become perverted.

    There was a time, not that many years ago, when requests for authorizations was unusual and typically for an expensive or unusual test or unusual dose or administration of a branded drug. Now there has evolved a routine requirement of authorizations for the most common and customary practices, standard tests, and especially medications. Generic medications. Often because the insurer has decided as a business measure to favor some medications over others not based on any medical standards or efficacy. It's routine use by insurers means it has ceased to become meaningful as any sort of responsible oversight and instead is in effect a form of harassment and pointless burden to office staff who now spend tremendous time on just this aspect of patient care. This creates real cost and has been unilaterally imposed by insurers at the expense of the medical providers and also the patients, their supposed paying customers with whom insurers now have an adversarial relationship rather than a custodial one.

    I would advocate for additional measures to either require insurers to bear the cost of such practices (remember that the imposition of authorizations is an arbitrary insurance requirement, not a medical one) and to limit there use when requests meet accepted practices regardless f whether the test or more often medication, is on some preferred list.

    Continually adding burdens to providing medical care is no longer just for the extreme cases of expensive tests and exotic or expensive treatments but for all routine care now and it intolerably interferes with the practice of health care delivery, patient safety, and the shared medical decision making of a patient and their provider.

    Anthony May, MD

    President, Pennsylvania Neurological Society

  2. Christopher Michael Burritt | Feb 23, 2018

    Is this really stunning to anyone? Given the number of denials we all routinely receive there is no way that they could correspond with actual records reviews. It's a shame that it has taken this long to more closely scrutinize this practice. I'm more upset with insurance commissions than the insurance companies these days. What a disgrace.

    Chris Burritt D.O.

  3. John Messmer | Feb 23, 2018

    I have patients who were approved in multiple prior years for therapies and every year we must go through the process again. One patient for example has extensive coronary artery disease and severe hypertension and hyperlipidema and every year I must certify that the medication combination is correct.

    Rather than focus on speeding up the prior auth process or insisting each case actually be reviewed, we should focus on total elimination of prior authorization. They claim it saves patients money but I think that is a lie. I think it only saves the insurance company money. They should be made to open their books to audit to see exactly how much is "saved" and how much goes to reducing premiums or otherwise saving money for the patient.

  4. Robin Scheiner | Feb 22, 2018
    I am a Dermatologist.  I recently had an 84 year old woman complain to me of hair loss.  Anyone who went to medical school knows that hair loss can be caused by a variety of medical conditions including thyroid disease, connective tissue disease and iron deficiency anemia as well as primary lesions of the skin like lichen planopilaris.  One cannot say if the hair loss is medical or cosmetic in nature util a proper work-up has been done.  I did the work up for alopecia and had all care related to that complaint denied by Coventry Healthcare, which is an Aetna Company.  They denied the visit and all work up saying that alopecia is a cosmetic condition.  One cannot say that alopecia is a cosmetic condition until one has ruled out all medical causes of alopecia.  I wrote an appeal letter explaining just that and the visit and payment for lab fees were still denied. Unfortunately, the Pennsylvania Insurance Commission only accepts complaints from patients, not physicians, so I had to encourage this 84 year old patient to go online and file a complaint with the Insurance commissioner.  I suspect that no one with a medical degree actually reviewed this claim, or if they did, their primary concern is not patient welfare but finances.
  5. Pierce Soffronoff | Feb 22, 2018

    I am a DEA certified prescriber of medically assisted treatment of opioid dependency, and I am also a  member of a large consortium of likewise certified providers of "Suboxone" with affiliated offices throughout western PA.  As such we as group, some 40-50 providers from all specialities, use a central prior authorization ("pre-auth") center for Suboxone-like medications.  Despite increasing improvements in the system, there is unnecessary delay by enough health plans to place these victims (of past over-prescribers of opioids ) at risk for overdose (too often under-reported) via the frequently fentanyl-laced illicit opioids, cocaine, amphetamines, and of course heroin.  I recognize that Dr. Christopher's comments above are directed at medical and diagnostic (and potentialy surgical) requests by patients who already are under a provider's care, but many illicit drug users have the coverage but need every assistance possible to proceed with "pre-auth."

    There is always more that can be done to stem our national opioid crisis. Steam lining "pre-auth" is one of them. 

    Pierce Soffronoff,MD

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