Here’s the dirty secret of emergency medicine: We don’t have to do prior auth. Like ever. We just order what the patient needs, and the patient gets it done in the ED. But here’s why we care about prior auth anyways: B/c not a shift goes by where a patient doesn’t land in the ER as a last resort when #priorauth denied or delayed them the outpatient care they needed.
Need your gallbladder taken out electively? Too late (waiting for auth), now you’re in the ED with cholecystitis. Had a “nodule” seen on a CT, but couldn’t get a repeat scan authorized…ever? Now it’s metastatic and you’re in the ED for crippling pain. DVT? No problem, started you on blood thinners. Oh, but your insurance wouldn’t cover it? Wait for it…now you’re hypoxic with submassive PEs. You’ve been having severe migraines, and insurance requires you to do a “trial of meds” before getting a MRI. The meds don’t cut it, you’re in the ED and turns out, you have an aneurysm. And it’s bleeding. The examples go on.
Why does this matter? 1. It’s terrible for patients 2. It stresses the healthcare system in ways it shouldn’t 3. It’s cumbersome and wasteful to insurers and clinicians both
35million priorauths submitted to @MedicareGov #MedicareAdvantage in a year - assuming 5 min/each and $20/hour of staff time (underestimated since this is physician/RN/admin blended time) that’s $58million of just labor cost. Not including denials/appeals…
So why does #priorauth exist?! To “contain costs” by insurers… Doesn’t sound terribly cost effective, does it? 😑 $58 million in labor cost alone of initial submission, not including the labor cost of denials/appeals and not including the cost of ED/hospital stays that results from delays/denials… Sounds like it’s time to get rid of #priorauth, no?
@amyfaithho Getting rid of prior auth is long overdue. Same goes for medication formularies. It’s more about control than $$. I actually don’t think they care about or believe they are saving $$.
@IMWHorvitz @amyfaithho Oh they DEFINITELY think they are saving money. Bc they are looking at the short-term costs only. Bc they are only taking into account the “financial burden” on the insurer, not the potential real lasting damage done to the insured.