Fraud in Medicine: Prior Authorization I

— by Katy Ottaway MD

Prior authorization is where, in the insane United States medical system, the doctor orders a test or medicine. The insurance requires “prior authorization,” that is, the doctor or their office have to call or go on line to fill out forms to get the prior authorization. Otherwise the test or therapy or medicine or even surgery will not be covered by the insurance and the patient eats the bill. Over 60% of bankruptcies in the US are now over medical bills.(1)

In most doctors’ offices, the prior authorization is done in the back rooms. Employees are on the computer or on the phone trying to obtain the permission, the code number, the magic words that will help the patient. This is a HUGE business and a scam as well. Physicians for a National Health Care Program estimated in 2011 that it costs at least $82,975 PER PHYSICIAN PER YEAR to have a person calling.(2)

Now, there is a person on the other end receiving that call or going over the forms. That person is paid with your insurance premium. Is that health care? It seems more like a barrier to health care. Let’s look at an example.

I do my prior authorizations in the room with the patient. I only have a front desk person, no back room people, and anyhow, if I do it face to face with the patient, I can charge the insurance company for the call. It is face to face counseling and coordination of care. I don’t get paid well for this, but it’s worth it for the patient education.

Yesterday I called for a patient. The insurance company first has a recording that tells me it is recording this conversation. I am too, in the chart note. Then it reminds me I could do all this on line. Well, that is sort of true. I could, but every insurance company has a different website, they all require logins and passwords and it would take me hours to learn them all. Nope, not doing that.

After the message it says: “Please enter the physicians NPI number.” I do. Then it leads me through choices: confirm the patient is insured, check the status of a prior authorization, appeal a prior authorization, initiate a prior authorization. That one.

At 3 minutes 50 seconds, I get a human. We are on speaker phone.

“This is Rex. You are calling for prior authorization?”

“Yes. This is Dr. Lizard. Mr. X is in the room.”

“Please spell the doctor’s name.” They are not used to doctors calling.

“Please give the NPI number.” (ok, we typed that in. But every time you are transferred, you have to give all of the information again. I am not kidding.)

“Please give your clinic address. Please give your clinic phone number. Please give your clinic tax ID number. Please give your clinic fax number.”
I do.

“Please give the patient id number. Please give the patient name. Please give the patient date of birth.”
Ok.

My patient is looking amazed. This is how insurance companies treat the doctors who call them?
Yep.

“What medicine are you authorizing?”

“A compounded testosterone.”

“Please list the ingredients.”

Crap. didn’t think of that. “Ok, we want to authorize an fda approved one.”

That is entered. “What are the instructions for the patient?”

“What is the dose or strength?”

“What is the diagnosis?”

“He has a condition from birth with no testosterone.”
I have to spell the condition for Rex.

“What is the ICD 10 code?”
I give that.

“Have you measured a testosterone level?”
“Yes. It’s zero. His body doesn’t make testosterone. Since birth.”

My patient is rolling his eyes.

“The form will be sent for review and you should get a fax within 24-72 hours regarding the authorization. Here is a number for tracking.”

“Thank you, we are recording this phone call as face to face counseling and coordination of care in the chart.”

Phone call is 13 minutes and 50 seconds. That is a fast one, actually. Most are 25-30 minutes and I
fought for an hour once when a patient’s prescription coverage was cancelled.

I wish that every doctor in the country would do one prior authorization on the phone once a week with the patient in the room. The doctors’ heads would blow off. They might finally see what the current system is doing and how the insurance companies throw more and more and more barriers up to refuse people care.

And how is it a scam? One way is that the patient calls the insurance. The insurance has people who only talk to patients. That person says, “Have your doctors office call for a prior authorization.” The patient calls the doctor’s office. The doctors office calls the insurance, but they are talking to a different branch of the insurance company. That branch tells the doctors office “We don’t cover that.” The doctors office calls the patient, who then thinks that the doctor’s office has screwed up the prior authorization.

How do I know that? With the person in the room, the insurance tells me “No.” I have had patients say, “Your company told me yesterday that all I needed was for the doctor to call!” The insurance person replied, “I only talk to doctors. It is another part of the company that talks to patients.” I have also had an insurance person say “Take me off speaker phone, I am only allowed to talk to physician’s offices, not to patients.” Riiiiiight. I took him off but put him right back on. My patients are outraged and furious: at the insurance, not me. The insurance companies are doing brilliant business plan triangulation and I hope whoever thought it up and whoever allows it as a business plan roasts in hell. No, instead I hope that they wake up and realize how many people they are hurting and I hope that they turn and work to heal a broken sick system.

(1) http://www.pnhp.org/new_bankruptcy_study/Bankruptcy-2009.pdf
http://www.pnhp.org/sites/default/files/docs/Bankruptcy_Fact_Sheet.pdf

(2)http://www.pnhp.org/news/2011/august/us-doctors-administrative-costs-4-times-higher-than-in-canada
http://www.pnhp.org/news/2014/august/adventures-in-prior-authorization

Reprinted with kind permission of Katy Ottaway, MD, from her KO Rural Mad as Hell Blog