Recently, I saw my oncologist for a follow-up. Mostly good news. I am coming up to an anniversary. It is becoming less and less likely that my cancer will recur. Lab tests are looking better. And he ordered the annual follow-up imaging, something that would require preauthorization. Since it's to be done a few months down the road, I began to think about when I should start calling the insurance company to explain why I needed this test. Should I wait for the denial or be pre-emptive? Each year I have been denied, then after I called and demanded to speak to the oncology reviewer, who then approved the test.
I am a physician. I know the lingo. I can talk to the oncology reviewer and explain my case. But, what of my patients? It's clear why they might slip through the cracks. If the clinic nurse doesn't "bird-dog" every study for utilization approval, call when needed, and involve the doctor when needed, studies and procedures may not get approved. The denial may slip past. The patient may return to clinic, unable to get the study, and not know why. It's unlikely for a patient to know where to start. And, even if they did, many of my patients don't know English, or not speak it well enough to address the denial themselves. They must rely on their doctors and nurses to intercede for them. Yes, that is part of the job, but on the day to day basis, it often seems there are more urgent problems to deal with.
Today, a colleague was venting about how hard it was to get things done, to get referrals or studies. We discussed the process for a patient with a herniated disc. He talked about how hard it was to get a specialist referral. Sometimes it could be months, he said. Our nurse chimed in to say that we usually schedule the patient within 2-3 weeks of receiving the referral. But, we want imaging done first. So, the patient has already had to jump through the pre-approval hoop twice. Once for the MRI (or sometimes CT), and once for the specialist consult. Maybe a third time for physical therapy. Each of these may take 2-3 weeks with someone "bird-dogging" the referral, longer without. And, then, after seeing the surgeon, maybe more physical therapy and possibly a pain clinic referral, with more pre-authorizations. Sometimes, each of these steps has to go back through the primary care provider. And, after that, if the patient doesn't improve with conservative care, yet another pre-approval process for surgery. So, it can be a slow process at times. The American version of waiting lines for surgery. For some surgeries, this may not be a bad idea, since many patients may recover on their own from some problems. Often they do with disc problems.
But, what of other problems? The answer is that it varies. Emergencies don't go through the pre-approval process, but rather retrospective review. While I was off due to my illness, and some since, I have done some of these reviews. For all, the key to approval is documentation. The provider must clearly document the reason for the test or procedure. This is good medical practice. Sometimes, as a reviewer, I have been able to infer why something is being done, but the documentation must be there, and it must fit in the boxes defined as approved by the insurance company. Sometimes, there isn't enough documentation, so there is simply a denial. Sometimes, the reviewer may need something clarified. Mostly, once the information is made available, the request makes sense. Sometimes, it doesn't. These are the tests and procedures that probably should be denied.
This process may take some time. Some patients get lost in all of this, and come back angry that "nobody cares." Their problem didn't get better, and may have gotten worse as they stumble through the system.
To me, this seems like the American version of the waiting lines for treatment in other countries. We wait at each step of the way. Sometimes, patients get frustrated and feel there is no way to navigate the system. And, so, the insurance company saves the money they otherwise would have had to spend. The American version of the "R word," rationing. It is a system of rationing that affects those who are least able to speak eloquently for themselves more than those who can. So, the most vulnerable may not get the care they need. And, so we see income disparities in length and quality of life, since income may serve as a marker for education and status. This seems why so many candidates for office don't want to address the issue of rationing, because they would need to admit that we already have rationing, that America has financial rationing of health care. And, it affects nearly all of us. Since, even with private or employer sponsored insurance, most of us have HMOs or PPOs, so our insurances have forced this upon us.