Episode 3: The Prior Authorization Games: Where the Odds are Never in Your Favor

Last updated on March 17, 2019

Post updated 3/13/19

Welcome to Episode 3 of The Prior Authorization Games:   Where the Odds are Never in Your Favor.

In which I chronicle more examples of how to fight insurance company denial of services.

My latest and most flabbergasting interactions with the insurance companies when requesting “prior authorization” for necessary medical care for my patients.

First, a quick explanation of the title of this post series (be sure to read Episode 1 and Episode 2, if you missed them):

Just like in The Hunger Games, in The Prior Authorization Games, doctors are pitted in unwilling (verbal) battle against their peers.  Our arena?  The insurance company.  Extreme analogy, you say?  While we are not battling to the death (at least, not yet), we are fighting for the lives of our patients.  And this is not fiction, it is reality.  A few case examples will follow:

Case #1*:

My patient is a woman in her mid-forties with stage IV cancer, who is stable on chemotherapy. She has had stage IV cancer for several years.  With chemotherapy, her disease is in control.  She lives an active life, raising kids and continuing to work a job outside the home as well.  She required a procedure that necessitated a pause in the currently effective chemotherapy for 2 months.  Once she recovered from the procedure, we scheduled the re-start of her chemotherapy.

But her insurance company denied coverage of the chemotherapy. To appeal, I needed to do a “peer-to-peer” phone call with a physician at the insurance company.

This should be easy, I thought.  It was probably a matter of the initial approval date expiring.

Surely they wouldn’t deny a currently effective therapy.

I could demonstrate that the patient was on a chemotherapy that was working against her cancer, and it should be straightforward to get it re-authorized.

It was the usual hassle to schedule the phone call (at the convenience of the insurance company physician, not taking into account my schedule) and interrupt my time with other patients. But once on the phone I thought this one would be a slam-dunk.

I should have known better.

I should have remembered the clinician’s dogma of experience with prior authorizations:  where the odds are never in your favor.

As the physician on the phone said ‘no’ repeatedly, I requested to know his specialty.

To my surprise, he said he was also a board-certified medical oncologist.

“Well, that’s terrific!”  I said.  “This is the first time I’ve done a peer-to-peer call and actually been able to speak with a fellow oncologist.”

I went into a level of detail about the patient’s treatment that could only be appreciated by another medical oncologist.

But he interrupted me.

“How did you get this chemo approved in the first place?”  he demanded.

Wait — what?

This led us to a debate about the NCCN guidelines (National Comprehensive Cancer Network) and the role of this particular chemo.

I finally had to interrupt.  “I think you’re missing the point – whether or not you agree academically with my choice of this chemotherapy – it is working – we have radiographic proof of response.”

He hemmed and hawed some more and finally, finally!, agreed to re-approve a therapeutically effective treatment.

His last words stuck in my mind.  He ultimately decided he “could live with” my choice for the patient’s chemotherapy.

At that point, I bit my tongue, because he finally gave me an approval number, which was what I needed for my patient’s care.  Ego had no place here.

I kept these thoughts to myself –“Oh, well, of course, that’s what’s really important here.  I’m so glad you can live with it.  Because my patient actually needs this medication to live.”

The recent news that a former medical director at Aetna admitted under oath that he did not look at the medical records when denying authorizations, came as no surprise to any physician in the U.S. in current practice, anywhere.

As I argue in Episode 1, why is the process of board certification not enough?

Why does the U.S. healthcare insurance system not trust that board-certified specialists who order tests and treatments are doing so in the best interests of our patients and according to standards of care?

Why have a board certification process at all, if the ultimate decision on the approval of a test lies with a physician, often in an unrelated specialty, employed by the insurance company?

In prior posts, Episode 1 and Episode 2, I give some further examples of cases, and of strategies that worked, in addition to helpful links to other posts by physicians on how to fight insurance company denial of prior authorizations.

Case 2:

Along that line, next I want to share an excerpt from a letter that succeeded in obtaining approval for a PET scan that had been denied.  I hope this example might be helpful to my peers.

As other physicians have recommended (see again links above), citing evidence and guidelines, and pointing out the patient harm that will result from the denial by the insurance company, is often a successful strategy.

In this particular case*, myself and my staff had appealed on behalf of the patient for over 1 month.

It was imperative that we obtain a repeat PET scan to determine if the treatment was working or not.

For unknown reasons, this company would not allow a peer-to-peer call.  (That’s right — when we asked to speak to the medical director, we were refused).

They did finally say I could write a letter.  Here is an excerpt of what I wrote:

Treatment decisions for my patient hinge on whether there is interval change by PET/CT scan.

As per the NCCN Guidelines Version 4.2017, Invasive Breast Cancer, with NCCN Evidence Blocks, PET/CT scan is a validated measure of disease progression.  To directly quote the NCCN guidelines, “The most accurate assessments of disease activity typically occur when previously abnormal studies are repeated on a serial and regular basis.  Generally, the same method of assessment should be used over time.”

(https://www.nccn.org/professionals/physician_gls/pdf/breast_blocks.pdf)

Your denial of the PET/CT scan, in direct contraindication of the NCCN guidelines, is hindering the care of my patient.  Already we will have to delay a treatment decision because the PET/CT scan we had scheduled for her had to be cancelled when it did not receive a prior authorization.”

A few days later, my staff were on the phone still trying to schedule the peer-to-peer review call for me, when, lo and behold, they were told a call would not be necessary —  the PET/CT scan was approved.

Case 3:

One final case example for this post.*  Another day on the phone, doing yet another peer-to-peer call (does it seem like I spend a lot of time doing this?  I do!  As do all my colleagues…).

The reason for this call was to obtain prior authorization for an MRI scan for a patient with a new diagnosis of lung cancer.  It is an oncologic standard of care (and in the NCCN guidelines), to obtain an MRI of the brain at the time of diagnosis, even if the patient has no particular symptoms related to the brain.

The conversation was going around and around, as the physician I spoke to could not seem to accept this.

Remembering my experience in case 1 above, I politely asked what the physician’s specialty was.

Cardiology, she told me.

I took a deep breath and (again, politely) explained the NCCN guidelines and rationale for staging MRI of the brain.  It was clear she did not want to approve it, but it also must have been clear to her that I was not getting off the phone without the approval.

“Fine!”  she ultimately said (angrily), and gave me the approval number.  “But I have never heard of this,” she insisted.  “Why don’t you just get a PET scan!?”**

Thunk. 

(sound of my forehead hitting desk).

*details in all cases changed to protect patient privacy

** the patient did have a PET scan.  PET scans are not sufficient to stage the brain.