Although prior authorization can prevent physicians from administering unnecessary tests, there are barriers that can complicate practice. This author details how to deal with a sometimes-complicated process and provide the best care for patients.
As each day goes by, it seems that regulations and red tape in wound care are increasing, and the hurdles to provide the best possible care ratchet higher.
In the trenches, practicing physicians who try to provide the best care for each of their patients are experiencing burnout. For example, some physicians, including the author, do peer-to-peer reviews every week with insurance carriers to make sure patients get the care they deserve. Sometimes, the peer-to-peer decision brings about concern, especially regarding the care of the patient, as it is difficult to grasp how an unrelated doctor reviewing a chart can make a better decision than the treating physician.
A typical day-to-day struggle involves the common expectation held by insurance companies that an X-ray must be done before a computed tomography scan or magnetic resonance image. In the author’s practice treating chronic wounds, an X-ray can often be considered a waste of time and money, as the author is typically looking for an abscess or osteomyelitis. The changes in chronic osteomyelitis can take weeks or even months before they can be seen on an X-ray, but an X-ray must be issued, even when it is not necessary, as a result of the requirement from insurance companies.
In addition, both peer-to-peer review call and prior authorization are required to obtain approval for hyperbaric oxygen therapy (HBOT), negative pressure wound therapy (NPWT), and cellular- and tissue-based products (CTPs). Indications and guidelines can drastically vary among providers, especially private insurance companies, and violation of the guidelines can occur, despite following those guidelines set out by the Centers for Medicare and Medicaid Services (CMS), the Undersea and Hyperbaric Medical Society, and the American College of Hyperbaric Medicine.1–3 It should be noted that numerous insurance carriers have placed many CTPs into the experimental category.4 For example, the BlueCross/BlueShield Federal Medical Policy does not identify compromised skin grafts/flaps as a covered diagnosis.5
Furthermore, during the discharge planning process, many physicians are required to do peer-to-peer review, as coverage criteria for long term acute care have changed; many insurance carriers usually prefer to direct their patients toward low-cost centers rather than paying for long-term acute care. Insurance medical directors often argue they can provide the same standard of care in skilled nursing facilities, so acute long-term care is not necessary.
Why Clinicians Are Frustrated With Prior Authorization
Prior authorization has led to much frustration in the clinical community. In July 2018, the American Medical Association (AMA) launched an online project as a direct result of this frustration.6 Since then, the website has had 15 million impressions and over 490,000 engagements, 610 patient and physician stories captured, 90,000 petitions signed, and 270,000 messages sent to Congress.6 According to a recent AMA survey, 86% of American physicians rated the prior authorization burden in their practices as “high” or “extremely high,” and 50% said the burden has “increased significantly” in the past five years.7
This is an issue that extends past the physicians. Patients suffer the most because of the possibility of delayed care or no care. The same AMA survey reported that 91% of physicians said the prior authorization process had a significant or somewhat negative impact on their patients’ clinical outcomes.7 The survey notes 75% said wading through the delays, denials, and appeals led to patients abandoning their recommended course of treatment, and 28% reported that prior authorization intrusion led to a serious adverse event for a patient under their care.
The Texas Medical Association had a significant win with the passage of Senate Bill 1742 in June 2019.8 The new law, effective as of September 2019, requires state-regulated health plans to post any prior authorization requirements on the internet. In addition, it opens the door for utilization reviews to be conducted earlier in the appeal process; these reviews can be completed by a physician in a similar specialty or the same specialty as the physician requesting treatment approval. This law aims to help both physicians and their patients. Physicians can further help their patients by becoming involved in organized medicine and passing similar bills at the state and federal levels.
There are a few things that a physician’s office can do to make the process easier.
1. The physician’s office should print out the latest medical policy on the procedure with an authorization request for the patient.
2. Make sure everyone on the team is familiar with the documentation requirement(s) (i.e., most insurance carriers will ask for the latest hemoglobin A1c, prealbumin, and documentation of failed standard care).
In addition, physicians should ask two questions before starting a peer-to-peer conversation:
1. Is the doctor conducting the peer-to-peer review from your state?
2. Is the doctor conducting the peer-to-peer review of the same specialty?
In the case of denial, the physician can always appeal the decision by asking for standard external review. Patients and physicians have the right to fight the decision by asking for a review by independent health care professionals who have no association with the insurance company. In case of an urgent or emergency situation, an expedited appeal can also be requested.
Physicians must document their peer-to-peer conversation in the patient’s chart if the physician conducting the review is from same state and if he or she is making decisions on the management of the patient. It will be curious to know whether utilization review is considered the practice of medicine. Can complaints against peer reviewers or insurance medical directors be reported to the medical licensing board?
A Closer Look At Texas’ Peer-Review Policies
It is also important to review state licensing board and state medical association policies concerning the peer-review process. The current opinion of the Board of Councilors of the Texas Medical Association (TMA) outlines the role of insurance medical directors, medical necessity determination and utilization reviewers, and determines whether these roles pertain to the practice of medicine.9 Of note, the TMA Board of Councilors serves as the ethical, policy-making body of the association. Opinions of the Board of Councilors at TMA are based on the AMA’s Principles of Medical Ethics, current law, and the board’s authority to investigate the general ethical conditions about the practice of medicine in Texas.
According to the TMA Board of Councilors:
Medical Directors.10 Simply because a physician is not providing direct patient care does not mean that the physician is not practicing medicine or obligated to adhere to the principles of medical ethics. Whenever physicians employ professional knowledge and values gained through medical training and practice, and in so doing affect individual or group patient care, they are functioning within the professional sphere of physicians and must uphold ethical obligations. This is true not only if the physician is making determinations of medical necessity or coverage, but also if the physician is involved in developing a health plan’s general policies that affect patient care, e.g., utilization guidelines.
Medical Necessity.11 The determination of medical necessity is the practice of medicine; it is not a benefit determination. Whether or not a proposed treatment is medically necessary should be decided in a manner consistent with generally accepted standards of medical practice that a prudent physician would provide to a patient for the purposes of preventing, diagnosing or treating an illness, injury, disease or its symptoms. This is true even if the physician making the medical necessity determination is making those decisions on behalf of a managed care organization. That physician must not permit financial mechanisms to interfere with his/her determination as to whether a treatment is medically necessary. Although the physician may take cost considerations into account, the physician may not refuse to approve the medical necessity of a treatment simply based on cost, and must approve the treatment if it is clearly more therapeutically effective than other treatment options that may be covered under the plan, even if those treatment options are less expensive than their more costly counterpart.
Utilization Review.12 The physician who performs prospective and/or concurrent utilization review is obligated to review the request for treatment with the same standard of care as would be required by the profession in the community in which the patient is being treated.
The TMA has a policy regarding the same issue.13 Policy 145.024, Medical Decision Makers Licensed in Texas, states:
Medical Decision Makers Licensed in Texas: The Texas Medical Association will (1) support legislation that would amend the Texas Insurance Code to require utilization review agents to be supervised by physicians licensed to practice medicine in the State of Texas and all denials of care based on medical necessity to be made by physicians licensed to practice medicine in the State of Texas and in the same or similar specialty as the treating physician seeking authorization of medical care; and (2) work to amend the Medical Practice Act to include the supervision of persons performing precertification or preauthorization based on medical necessity as the practice of medicine; and include any denial of precertification or preauthorization of medical services based on a determination of medical necessity as the practice of medicine (Amended CL Rep. 1-A-08; amended CSE Rep. 5-A-16).
Prior authorization was instituted by insurance companies to ensure that physicians are not ordering unnecessary services and tests when the patient does not need them. However, to ensure proper patient care, the practice of medicine by physicians must remain sacrosanct.
There is a deep-seated gratitude for those who work extremely hard for their patients. When conducting prior authorization or peer-to-peer, keep the patient in mind and do the right thing. Hopefully these tips will help with the next peer-to-peer conversation.
Jayesh B. Shah is president of the American College of Hyperbaric Medicine and serves as medical director for two wound centers based in San Antonio, TX. In addition, he is president of South Texas Wound Associates, San Antonio. He is also the past president of both the American Association of Physicians of Indian Origin and the Bexar County Medical Society.
1. Centers for Medicare and Medicaid Services. Regulations & Guidance. Available at https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance. Accessed January 17, 2020.
2. Undersea and Hyperbaric Medical Society. Clinical Practice Guidelines. Available at https://www.uhms.org/cpg. Updated January 2020.
3. Serena TE, Gelly H, Bohn GA, Niezgoda JA. The American College of Hyperbaric Medicine consensus statement on physician credentialing for hyperbaric oxygen therapy. Adv Skin Wound Care. 2014; 27(8): 349–51.
4. Blue Cross Blue Shield Federal Employee Program. FEP 2.01.04 hyperbaric oxygen therapy. Available at https://media.fepblue.org/-/media/24346D3AADCB4D75BA5047AF2D59FB89.pdf. Effective April 15, 2018.
5. Blue Cross Blue Shield Federal Employee Program. FEP 2.01.04 hyperbaric oxygen therapy. Available at https://media.fepblue.org/-/media/1E835310A5754682BC2E5F5058D4BF7C.pdf. Effective April 1, 2019.
6. American Medical Association. Prior authorization hurts patients and physicians. It’s time to #FixPriorAuth. Available at http://fixpriorauth.org/. Updated 2019.
7. American Medical Association. 2018 AMA prior authorization (pa) physician survey. Available at https://www.ama-assn.org/system/files/2019-02/prior-auth-2018.pdf. Published February 2019.
8. Texas Legislature. Bill: SB 1742. Available at https://capitol.texas.gov/BillLookup/History.aspx?LegSess=86R&Bill=SB1742. Accessed January 17, 2020.
9. Texas Medical Association. TMA Board of Councilors current opinions. Available at https://www.texmed.org/Template.aspx?id=392#. Updated April 11, 2019.
10. Texas Medical Association. TMA Board of Councilors current opinions: medical directors. Available at https://www.texmed.org/Template.aspx?id=392#DIRECTORS. Updated April 11, 2019.
11. Texas Medical Association. TMA Board of Councilors current opinions: medical necessity. Available at https://www.texmed.org/Template.aspx?id=392#NECESSITY. Updated April 11, 2019.
12. Texas Medical Association. TMA Board of Councilors current opinions: utilization review. Available at https://www.texmed.org/Template.aspx?id=392#UTILIZATION. Updated April 11, 2019.
13. Texas Medical Association. 145.024. Medical decision makers licensed in Texas. Available at https://www.texmed.org/Template.aspx?id=42851. Updated October 7, 2016.