ISMA’s practice management consultant Jan Hailey, MHL, CMC, CMCO, CMIS, CMOM, CMCA-E/M, recently reviewed more than 120 examples of payors inappropriately putting prior authorization over patients. The examples were submitted to ISMA by Hoosier physicians and other health care professionals as part of the Patients Over Prior Auth initiative.

The majority of complaints so far stem from prior authorizations required for medication. Many of the requirements are for drugs that are standard treatment for the patient’s condition. Common complaints regarding the drug prior authorization process include: 

• Review by a peer in a different specialty.
• Need for prior authorization even after the patient has been on the medication for a period of time.
• Delay in prior authorization, leading to delay in treatment.
• Staff time required to obtain the prior authorization.

While the examples mention most insurance payors at one time or another, Anthem, UHC, and Medicaid are the most common.
Several entries reference diagnostic imaging that required prior authorizations; this often led to delayed treatment or required another test prior to the requested procedure. Several physicians stated they felt this led to a higher overall cost of care. 

Other issues included: 

• Delay in surgeries being preauthorized, preventing surgeons from being able to move the surgery to an earlier date when there is a cancellation.
• Inability to obtain additional in-patient days for psychiatric patients because the patient was not considered suicidal.
• Rehab admission prior authorization delays resulting in longer lengths of in-patient stay.

Thank you for continuing to advocate for the well-being of all Hoosiers. Your participation in this Patients Over Prior Auth initiative will help bring about vital change. 

Please continue to share your prior auth stories with us at www.ismanet.org/patientsoverpriorauth. ISMA will continue to update members on developments in the coming months.

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