Page 10 - Delaware Medical Journal - May/June 2019
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PRESIDENT’S PAGE
The examining doctor explained he
to get x-rays that were negative. He was then denied for an MRI and directed instead to physical therapy. After 16 weeks of painful physical therapy and a total of four MRI denials, the insurance company agreed to the MRI that subsequently diagnosed the torn rotator cuff. Unfortunately, it takes only six weeks of lack of use for the rotator cuff musculature to become fatty. Lack of use caused granulation tissue to form around the injured rotator cuff and joint capsule. The orthopaedic surgeon advised against surgery given the atrophic musculature and the scarring. The orthopaedic surgeon asked, “Why 6
In Delaware, we have primary care physicians being denied payment when the physician providing the service is different than the physician whose name is listed on the patient’s insurance card. This is clearly a frivolous, unreasonable denial of Because they can and they believe that no one can hold them accountable.
What can we do?
• We need a law to stop frivolous denials of payments and services in Delaware.
REFERENCES
1. Drash, Wayne. “$91 Million Case Against Nation’s Largest Insurer is a ‘Clear Win’ For Patients.” CNN, January 28, 2019, www.cnn. com/2019/01/28/health/california-supreme-court-insurance- commissioner-decision/index.html.
2. Drash, Wayne. “Jury Delivers $25.5 Million ‘Statement’ to Aetna to Change Its Ways.” CNN, November 10, 2018, www.cnn.com/2018/11/10/health/aetna-verdict-oklahoma- orrana-cunningham/index.html.
3. Al-Agba, MD, FAAP, Niran. “Prior Authorization: Will They Become Damocles Sword?” The Health Care Blog, August 28, 2018, www.thehealthcareblog.com/blog/2018/08/28/prior-authorizations-will- they-become-damocles-sword.
4. Fink III, BSPharm, JD, DSc (Hon), FAPhA, Joseph L. “Does a Pharmacy Have Liability Related to Handling Prior Authorization Requests?”
5.
6.
Pharmacy Times, August 15, 2018, www.pharmacytimes.com/ publications/issue/2018/august2018/does-a-pharmacy-have-liability- related-to-handling-prior-authorization-requests.
Drash, Wayne. “When Insurance Wouldn’t Pay, Parents Funded Cancer Patient’s $95,000 Lifesaving Treatment.” CNN, August 17, 2018, www.cnn.com/2018/08/15/health/cancer-survivor-insurance-denial- battle/index.html.
Twedt, Steve. “A Growing Frustration: Asking Insurers’ Permission For Medical Treatments.” Pittsburgh Post-Gazette, April 30, 2018, www.post-gazette.com/business/healthcare-business/2018/04/30/ health-insurance-prior-authorization-appeal-medical-care/ stories/201804290027.
• We need to know who in the insurance company is responsible for the denial.
• We need to know the specialty, subspecialty, licensure status, and hospital staff privileges of the person doing the denial. The person doing the denial must have equal training and walk in the same shoes as the person requesting the medical service or medication.
• We need the cost of the prior authorization process to be borne by the insurer, not the patient and the doctor.
• The physician must be reimbursed to
in the prior authorization process.
Since the Affordable Care Act became law, a managed care organization (insurer) must spend 85% of money collected from premiums on patient care, and only 15% the money spent by the insurer in the pre- authorization process is counted as patient care (not overhead/cost of doing business), the cost is passed on to the consumer as higher premiums.
By using this formula, the insurers are claiming they do patient care. When a nurse practitioner or a general physician
denies a neurosurgeon or orthopedic surgeon the right to perform surgery on an insured patient, the nurse practitioner and the general physician are “practicing outside of their scope.” They did not complete a residency training program
in orthopaedic surgery or neurosurgery. They certainly do not have hospital staff privileges to perform orthopaedic surgery or neurosurgery.
According to the 2017 American
Medical Association (AMA) prior authorization survey, prior authorization produces a three-day or greater delay
7 Approximately 97% of responders saw some patient abandonment of care, with 19% of the responders saying prior authorization “often” caused this outcome. Approximately 61% of respondents stated negative impact on patient outcomes.
patients and physicians in this epic struggle with the powerful insurance industry.
Andrew W. Dahlke, MD
President, Medical Society of Delaware
7. 2017 AMA Prior Authorization Physician Survey. AMA. www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/ public/arc/prior-auth-2017.pdf
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