Prior authorization: call for comments

The Washington State Medical Association has called for comments on prior authorization rule making for insurance companies.

Here is my reply:

I have a small solo family practice clinic. My business plan was arranged to spend more time with patients. I have an office manager and no nurse, no back office.

Thus all prior authorizations are done by me, with the patient in the room. Often patients have talked to their insurance company the day before and have been told “your doctor’s office needs to call us”. More than half the time, when I call, we are told that the patient’s insurance company does not cover that service. The patient says, “But I talked to your company yesterday.” The insurance representative responds: “I only talk to physician’s offices, that is another part of the company that speaks to patients.”

This is triangulation, where in the “standard” office, the patient has called their insurance. They call the doctor’s office as instructed by the insurance. The doctor’s office requests prior authorization. The insurance says it is not covered. The doctor’s office notifies the patient, who then assumes that the doctor’s office did something wrong, not that it’s not covered.

This is unacceptable.

I have stopped telling insurance companies that I am face to face with the patient, because some representatives say “I am not allowed to talk to patients, take me off speaker phone.” I document the name of the insurance person in the chart, the length of time for the phone call and I bill for time: counseling and coordination of care. Review by coders say that this is legal.

I suggest that every WSMA physician pick one day to call a prior authorization themselves with the patient present. This would reduce the insurance company triangulation.

I think that insurance companies should be required to tell a patient if a service is not covered, and not be allowed to say, “have your doctor’s office call us” for a service that is not covered.

Feel free to send YOUR comments to the WSMA!

I like slugs better than health insurance companies.

4 thoughts on “Prior authorization: call for comments

  1. Oh my unitarian god, WHERE ARE YOU??? I have looked for you all my life! Well, really just the last few years.

    Seriously though. Just came across your blog and am looking forward to reading all of it. Thanks!

    • drkottaway says:

      oh…heh…I read it as you were calling ME your unitarian god and I got kinda worried… phew. Second reading different…thank you….

      • no worries. I don’t even like that we have to “follow” other bloggers!! And that we know how many “followers” we have!

        And I just realized I had meant to make this comment on your “about” page, not this thought provoking one on insurance. I am a psychotherapist in private practice for over 35 years and stopped taking third party payments a long time ago for some of what you refer to above!

        Washington State, where I practice, is still recovering from a pretty dramatic pendulum swing in their rules and regs.Things were certainly different way back in the seventies! Healing arts of ALL kinds were still honored back then. Not so much now.

        Anyway, somehow the on switch got triggered there.

        Love your blog!

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