Increasingly, I am seeing coverage for medical tests being denied. Patients are becoming increasingly disenfranchised by their plans as they are paying more into the premiums and higher copays. All too often, insurance companies are asking for prior=authorizatons for services to be rendered and all too often they result in denials. I sometimes spend days in the battle of prior-authorizations trying to get a needed test orders. Many times I end up in a phone battle with the medical director of any given insurance company. Most often they are understanding what my patients need and will give approval. But, in recent weeks, denials have been more common. And these decisions are determined by someone who has had no direct contact with my patient or even spoken with them.
Of course, they always say that they are just determining medical coverage and not practicing medical care on my patient. They state that the patient is still free to get the test, they will just have to pay for it themselves. My patients cannot afford these costly tests, so yes it is making a medical determination for them. That is why they have insurance coverage. If they can afford their own medical care, they wouldn’t need insurance. Many Americans are depending on their coverage for their medical well-being. There is an agreement there that is be violating. Patients are not getting what they pay for.
This is not happening in regards to just diagnostic tests but also prescription coverage as well. In the past few weeks, I have had several asthmatics not be able to get their inhalers refilled because the formulary suddenly changed. They were unable to pay out-of-pocket because the cost was over $70 even for generics, not a cheap medication by any means. And as anyone knows, inhalers are life-saving medications for an asthmatic. No person should end up in the ER unable to breathe while these prior-auth games are happening.
And. these prior-auths are indeed harmful. How?
1, They delay needed treatment. Someone may have a life-threatening disease that cannot wait 3 days for the insurance company renders a decision. This delay is frankly putting lives at risk.
2. The delay slows down the process to finding the correct diagnosis. Sometimes test need to be done just to rule out certain disease before other tests can be done. The prior-auths slow down the whole process delaying correct diagnosis and prompt treatment.
3. Not knowing a diagnosis increases patients’ anxiety and fear. Doesn’t everyone want to know what is wrong with them as soon as possible. Many people lose nights of sleep worrying about this. Don’t they deserve a timely diagnosis.
4. It erodes the doctor-patient relationship. Many patients just don’t understand prior-auths and think the delay comes from the doctor. There is nothing further from the truth. Doctors spend hours in these battles when the patient is not there and most often aware. Most doctors truly care about our patients. Plus, there is increased liability in delaying treatment. No doctor certainly wants that.
5. Patients are often stuck taking substandard medication because the ones they need are not improved on prior-aith. I am all for generics and cutting costs. But, even many generic are now being denied.
While everyone needs to work on cutting costs, it should not be done at the cost of the health of the patient. Doctors are not running amok ordering unnecessary tests to drive up health care costs. We need to put more decision-making control back to the doctors who are actually examining and seeing the patient, not the nameless, faceless ones following their insurance companies’ cost-cutting guidelines. Patients deserve better than this.
Copyright secured by Digiprove © 2014 Linda Girgis, MD, FAAFP
