I have been working as an RN in a primary care clinic for nine months, and my experience with prior-authorization requirements is similar. This really highlights the problem with our third party payer system. Patients want unlimited access to expensive medications, specialists and imaging because they don't pay the cost of these things. Insurance companies make more money when they deny services, so they have thrown up a wall of red tape. Medical professionals are caught in the middle. Many times we don't even know that a medication wasn't covered until a patient calls weeks later saying that they never got the medication prescribed, and now they can't breathe, can't sleep, their blood pressure is out of control, or they end up in the hospital. I'm really surprised there aren't more lawsuits about this - but of course patients can't afford lawyers so they are just stuck, I guess.
My clinic has a department for referrals and insurance issues. When I started nine months ago there were three administrative people in that department (none of them had formal nursing or healthcare training). One staff member in that department was fired, another left on maternity leave, another got hired and then got fired. So we have one full-time staff member digging through chart notes and trying to process referrals and prior authorizations. Our office manager sometimes helps, when she has time. I do peer-to-peer reviews with insurance companies, which is successful about 40% of the time once the request finally gets to that step, often after multiple denials and resubmissions.
As you can imagine, we are several weeks behind on prior authorizations - and that is only counting the first submission of the request. Patients are waiting months or even more than a year to get an MRI, or they just never get one. To be fair, though, we have patients who refuse to do physical therapy, refuse to get labs done, no show at specialist appointments, and otherwise don't follow through with the steps required in the plan of care.
This situation has affected my personal medical care as well (through a different medical clinic). A change of insurance caused the need for a prior authorization on one of my own personal medications. Despite multiple phone calls and a letter from me, that medical clinic was not capable of going through my records and providing my new insurance company with documentation that I had already tried the alternative medications suggested by my new insurance company. I now get by without this medication, but my quality of life was higher when I was on the medication.
I have some ideas on how to improve the situation, but none of them are practical and easy to implement at the clinic level. One tremendous improvement would be to partially or fully integrate the computer systems of all medical facilities, pharmacies and insurance companies everywhere. I refuse to believe that this is impossible, though it may require new federal legislation to bring everyone to the table. Another improvement/solution might be integrated healthcare systems such as Kaiser Permanante, which mitigates the negative effect of our third party payer system. Or if we could put a pharmacy tech in every clinic, someone who could run medications through a payment system and come up with alternatives, that might be helpful. If insurance companies are going to continue to make things difficult, maybe insurance companies should be legally required to cover the cost of staffing for prior authorization departments.
I am on the computer and phone most of the day dealing with medication refills, insurance issues, and managing those unbelievably time-consuming and stressful controlled substance prescription issues. I spend more time doing this than doing real nursing activities like triage, education and medical follow up. Honestly, I'm looking for another job, perhaps in home health or a specialty office. I can't go back to working in unsafe, understaffed hospitals. It is early in my nursing career and I'm seeing a long and rough road ahead, for both patients and medical professionals.