03/02/2013    Jon Purdy, DPM

Pre-Authorization for Imaging (Bill Weis, DPM)

When I have to get on the phone with
some “doctor” to explain the medical necessity
of needed imaging, I feel sorry for that doctor,
the patient, and myself. Something has had to go
wrong in that physician’s world to have to, or
want to, work for an insurance company denying
medical treatments to insured patients.

As physicians, we have been through extensive
training and testing, and are required to
perform continuous training and testing in our
specialties. After all this, we find ourselves
being questioned as to the necessity of the
treatments and tests we want to perform on our
patients. This has absolutely NOTHING to do with
patient care. I am sure there is an insurance
utilization study out there that shows insurance
company cost saving as they put in place time
deterrents to patient treatment. I wonder if
there is case precedent where the insurance
company has been sued successfully for
interfering with patient care causing the
insurer to dispose of pre-authorization denials.

In the pre-authorization scam, the insurance
company will question all that has been done for
a patient up to the point of ordering of the
test. In my experience, at no point does an
insurer ask how long or to what degree the
patient has been suffering. These denials are
for patients who have been paying tens of
thousands of dollars in premiums, and even
patients that are willing to pay for the entire
test out-of-pocket, as long as it is applied to
their deductible. One insurer’s criteria went as
far as to deny a patient a lumbar MRI if
clinically, they were not experiencing advanced
neuro-degenerative changes and had not attempted
physical therapy.

Of course, doctors will be sued if they continue
care in the presence of undiagnosed pathology
that leads to impairment. The last thing I’m
willing to do to a patient with sever radicular
pain is send them to physical therapy to
manipulate a lumbar tumor, occult spinal
disorder, or any undiagnosed pathologic process
that could be worsened through spinal
manipulation. Does it not make more sense to
send a patient for a non-invasive, harmless
diagnostic procedure that can direct the proper
treatment course and alleviate pain and
pathology sooner? If an insurer wants to take
the “art” out of medicine and dictate treatment
protocols, then please lower my treatment
liability and malpractice insurance fees. If
not, then please stay out of my office so I can
provide the care the so-called “insured”
deserves.

Jon Purdy, DPM, New Iberia, LA,
jpurdy@mindspring.com

Other messages in this thread:

---

03/04/2013    Keith L. Gurnick, DPM

RE: Pre-Authorization for Imaging (Bill Weis, DPM)

Here is how I currently handle this situation.
On any patient where I order imaging done
outside my office, I inform the patient that
they must phone their insurance company before
scheduling the test to find out if a pre-
authorization or pre-certification is required.

Also they are instructed to get the name of the
person whom they spoke with. If pre-
authorization is not required, they are to
schedule the test. If, however, a pre-
authorization is required, the patient is then
required to obtain the phone number so that we
can speak with the insurance representative
to obtain such authorization before the test is
scheduled.

Either way it is documented in the record for
possible future reference. When
authorizations are required, I have my office
staff make the phone call and give all the
routine information (patient name, date of
birth, insurance ID numbers) to whom ever they
speak with. I only come to the phone when
necessary to answer any medical questions or
give the required clinical information if and
when it is above what my secretary can answer
from the medical record.

I estimate that 90% of the time, my request
(MRI, bone scan, CT, etc) is authorized by a
non-doctor however when the patient's
clinical information does not fall within the
insurance companies spec sheet of standard
guidelines, I get passed forward to a
radiologist who almost always "grants" me the
authorization after telling my story, including
why I need the test and what I have already
done.

Like the other doctors who chimed in on this
issue, I find this to be a big waste of my time
however I try to participate in these calls when
I am sitting at my desk doing other work like
charting, billing or eating lunch. Private
practice is so much fun.

Keith L. Gurnick, DPM, Los Angeles, CA,
keithgrnk@aol.com