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    Prior authorization and decision trees: Roots of my frustration


    The real problem I have is that not every insurance company follows the Joint Consensus Statement from the AUA and Society of Abdominal Radiology, which states that prostatic MRI should be “strongly considered” in “any” patient with a prior negative biopsy “who has persistent clinical suspicion for prostate cancer.”

    One recent example is a man in his 50s with an elevated PSA (6.0 ng/mL) but a negative biopsy 18 months ago. He did not tolerate the biopsy well from a pain standpoint and also developed a fever following the procedure. Biopsy showed no malignancy, but he missed all of his follow-up visits. A friend at his church was recently diagnosed with prostate cancer and he decided to get his PSA checked again via his primary care physician. It has doubled and is now 13. When he came to my office, he was obviously (and correctly) concerned but was almost in tears about the idea of a repeat biopsy unless it was absolutely necessary. We discussed the benefits of an MRI and I sent a very happy patient on his way.

    More from Dr. Rosevear: Men's health a forgotten topic

    But the insurance company denied the request for his MRI. I even had our nurse repeat the online preauthorization process on the assumption she made a mistake; denied again. I called the insurance company to initiate a "peer-to-peer" review and after presenting the patient and even quoting the AUA consensus statement, I was again denied. Why? The insurance company's algorithm is that the biopsy needs to be within 6 months. I asked what data they based that on and was met with silence.

    What can be done about this? While it may not help us urologists, at least the government acknowledges the problem and is trying to address it. Medicare recently attempted to streamline its prior authorization process for certain durable medical goods. Regarding the private insurance companies, I know of a much larger urology group than mine that went directly to the insurance companies and created agreed-upon criteria for various imaging tests. While that may work for a mega-group, I don't know how a small group like mine could accomplish that.

    On the positive side, one of the radiology groups in town recently offered to have its staff do the prior authorizations and that is certainly helping (and gaining them business), but that is simply moving the problem from one doctor's office to another.

    Read: The 'post-truth' world: How it's drifting into medicine

    Personally, I would like to see the patients get involved in the process. Specifically, if an insurance company denies a request, the patient should be given the responsibility to contact the insurance company and request it. Patients after all are the ones paying for the insurance. I somehow doubt that insurance companies would be as rude to their paying customers as they are to us. But then again, given my experience with insurance companies, maybe they would.

    I think the only chance we have is to educate our patients on how insurance companies seek to limit access to medical care and, by bringing them into the process, have the insurance companies change their behavior.

    But I'm not holding my breath.

    More from Urology Times:

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    Value-based pay in 2017: Where does urology fit?

    Telemedicine: Reimbursement in fee-for-service, quality models

    Subscribe to Urology Times to get monthly news from the leading news source for urologists

    Henry Rosevear, MD
    Dr. Rosevear, a member of the Urology Times Clinical Practice Board, is in private practice at Pikes Peak Urology, Colorado Springs, CO.


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