How Prior Authorization Delays Care and Frustrates both Patients and Physicians

How Prior Authorization Delays Care and Frustrates both Patients and Physicians with Dr. Mark Lopatin, MD

How would you feel if someone who didn’t know, was unfamiliar with your symptoms and story, and had never examined you dictated the way you were treated? Would you be upset if the people making those decisions were not specialists or maybe even had the same training as a physician? Unfortunately, this practice is very common today in every doctor’s office in America and it is called prior authorization.

Today’s guest, Dr. Mark Lopatin, is a rheumatologist in private practice who provides us insight today on what prior authorization is and why it is hurting patient care. He describes prior authorization as a process where third party payors (insurance companies both private and governmental) dictate the care being provided to their customers. They often use guidelines for treatment developed by specialty societies that are meant to be used as a guide for treatment – not as an algorithm to be followed blindly by physicians.

Not only does this treatment protocol fail to allow physicians to individualize the care they apply to their patients but it adds tremendous costs to the physicians in their offices. Now practices need to hire extra people just to justify the medical decision making on the phone or through emails which drives up the cost of care for private practices and large hospital organizations.

We are not only about problems but also solutions so here are the three reforms to prior authorization that Dr. Lopatin would like to see implemented.

1. Great Transparency: We need to have the true cost differences related to the restrictions on treatments or medications and the reasons those exist. They can’t just be buried in the legalese on some insurance company website.
2. Peer-to-Peer Reviews: Only people with a similar background to the treating physician can impede the authorization of treatments from the providing physician. It is ridiculous that someone might be specialist in say kidneys (nephrologist) making treatment recommendations to a cardiologist.
3. Insurance companies who deny care or change treatment should be held legally liable for their medical decisions: Self explanatory but if physicians are expected to be held responsible for treatment then so should those who change the way their patients are cared for by restricting or making erroneous recommendations.

Listen to the Podcast in its entirety:
THE PARADOCS PODCAST