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Preauthorization Medicine!

April 21, 2015

The full and absolute control of third party medicine in anything and everything has to do with the care of patients is real . Now this concept is going through a gateway of authorization. Preauthorization for any medical test ,procedure, office visit, medication to be dispensed, hospitalization, need of  Medical devices, durable equipment, oxygen, cane, walker, shoes etc. and the list goes on. 

The daily pains of so many physicians and their staff as they go through this everyday in an attempt to serve their patients; getting them what they need and well indicated and providing them with the appropriate medical necessities. 

When being confronted with preauthorization doctrines imposed by insurance companies for which the first response in about 99% of cases would be a denial. If a physician is to fight for their patient he or she may get lucky to get authorization for a test or a procedure that their patients  need on the third time around. Make no mistake about it you will be given an initial optimistic response "Oh yeah, its all covered by insurance" to find out the painful reality of going through the insurance system of preauthorization. For example, 88 year old medicare patient who has very high blood pressure and was put on so many blood pressure medications that failed and ended up in costly hospitalization that could have been avoided if the patient was given the specific medication that was appropriate to her condition.  After 18 faxes, 7 phone calls with the pharmacy explaining that this was the only medicine the patient could tolerate the answer was still that we had to call the insurance company to get it approved from which we would be given a case number. After calling the 1-800 number and  explaining for 25 minutes why the specific medication should be authorized for the patient we were told that this request would be reviewed by the pharmacy committee and the decision would appear in 24 hours. After the 24 hours however, the request for authorization was denied. As for this frail elderly patient was told that they would have to pay $6 a pill which they could Not afford as it was out of pocket although, this patient should have been given the medication with 100% coverage between medicare and her insurance. 

The time and energy wasted, the pain and suffering of this senior patient waiting for their medication to be authorized knowing that if patient doesn't receive it that they will be hospitalized, causing the system  thousands of dollars which could have been avoided if the medication had been authorized as it was made available in low cost generic form. 

Similar stories like this happen to patients across the country on daily basis  proving how inefficient, costly, and stressful this system to both patients and caring providers. The saga goes on for this elderly cardiac patient at no avail. 

Preauthorization medicine was designed to save money to insurance companies on high utilization providers but patients are not getting the care they need or deserve. Someone will never be given the preauthorization on therapy or a procedure that could be lifesaving which will be delayed and pushed back and in the mean time the patients condition may deteriorate and in some cases may never get the therapy or life saving procedure until they are deceased by the time they get the authorization!. 

The evidence -based  Medicine clinical guidelines are already well established for each disease category and therefore , they should be the guiding force for preauthorization medicine. 

Dr Adel Eldin,MD, FACC,FACP
Board Certified Cardiologist
President, Clinical Appeals Services
Founder, CEO
Affordable Quality Healthcare Program
Founder, CEO
Wesley Chapel , Florida
President ,Society of Physician Entrepreneur, Tampa Bay Chapter

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