The prior authorization system is seen as flawed by many surgeons working in orthopedics, spine surgery and beyond.
It often slows down patient care, adds administrative tasks for employees and sometimes even leaves physicians to foot the bill for expensive patient procedures.
Three neurosurgeons, Anthony DiGiorgio, DO, Praveen Mummaneni, MD, and Luis Tumialan, MD, issued a statement to Becker's explaining the major problems physicians face when it comes to receiving fair payments for services offered.
"Consider the following two scenarios: Imagine a broken pipe is causing a flood at your home. Your next steps are to contact your insurance carrier, open up a claim and then find a contractor to assess and repair the damage. The contractor provides your insurance company with a bid for the proposed work, which the insurance company reviews and approves. Upon completion of the work, the contractor submits for payment. The insurance company pays the claim.
"Now imagine you have a grade 1 L4-5 spondylolisthesis. After years of nonoperative treatment, you see a surgeon who recommends surgery. The surgeon completes a prior authorization of the proposed procedure which your health insurance carrier approves with the caveat, 'prior authorization is no guarantee of payment.' The surgeon performs the procedure as stated with great results. You are genuinely surprised to find out at a post-op appointment that your insurance carrier denied your surgeon payment.
"The surgeon's business office then begins the process of filing appeal after appeal over the next several months and ultimately writes off the balance. Thus, the surgeon performed the surgery for free on someone with commercial insurance. The first house flood scenario is how the real world works. The second scenario happens in 1 out of 10 spine surgeries. Denial of payment after prior authorization has become a grim reality of American healthcare.
"As bewildering as it may sound, insurance companies authorize procedures. Surgeons perform them as authorized. But then, the insurance company denies payment. No other industry functions in this manner. No other industry would tolerate this system. Yet, in healthcare, physicians, bound by their oaths to care for patients, endure a system that withholds payment. Surgeons put up with prior authorization, payment delays and overwhelming administrative tasks.
"Why even maintain a prior authorization system if it serves as nothing more than a mirage? Is it a placebo for surgeons? The prior authorization lulls the surgeon into a fabricated sense of security that they will receive payment for their services. Ultimately, patients bear the brunt of this charade. When insurance companies do not uphold their end of the bargain, surgeons face limited options. Many will not bill patients directly, refusing to fault individuals whose only misstep was choosing an unreliable insurance carrier.
"Patients have the right to a top-tier health system where they can select their surgeon. They deserve insurance companies that uphold their contractual promises. The transactions between surgeons and commercial insurers should be no different than a contractor and home insurance carrier. Work completed must result in work paid. It is high time insurance companies fulfilled their contractual obligations just like every other industry."