Here is a true story of a vibrant and young 30-year-old female who had symptoms requiring an MRI by her doctor. Her insurer denied the request to perform an MRI, claiming the patient must undergo six weeks of physical therapy first. The patient complied with the insurer’s demand, underwent the therapy, but came back to the clinic no better. A board-certified treating physician ordered a thoracic MRI, which had been originally denied by the insurer, but the insurer delayed it for two additional weeks. Only after the physician was able to obtain a peer-to-peer consult with the insurer’s consulting physician was the MRI approved. By that time, the patient was confined to a wheelchair, paralyzed from the waist down. The treating physician immediately referred the patient to a neurosurgeon, but the patient never regained the function of her legs and never regained bowel or bladder control. This heartbreaking example is one of many who are living with the consequences of denials and delays by their insurer, jeopardizing health outcomes for far too many Mississippians.
While insurance is a pivotal part of our healthcare system and prior authorizations serve a purpose if implemented correctly, excessive delays and denials are commonplace and can lead to costly hospital stays, spreading cancers, diminishing health, and even premature death. It is vitally important we allow physicians to diagnose and treat patients rather than its being dictated by insurance companies.
Lawmakers have proposed legislation this session that would reform the prior authorization process and offer relief to Mississippi patients and the providers who treat them. This bill is fully supported by the Mississippi Independent Physician Practice Association (MIPPA) for which I serve as President. Much of the problem is avoidable by re-evaluating a broken insurance system that adds costs and slows care through onerous administrative burdens. These commonsense solutions include:
— Insurers posting a current list of services requiring prior authorization so it is readily accessible and available to all patients and providers;
— Adequate notice to patients and providers of changes to prior authorization requirements;
— Requiring insurers to respond to a prior authorization request within a reasonable timeframe for both normal requests and urgent healthcare services;
— Public access to prior authorization statistics on the Department of Insurance website (e.g., total number required; total number denied; top reasons for denial; average wait times, etc.); and
— Standardized electronic prior authorization procedures.
If an insurance company requires a prior authorization, it should also have the capacity to hire board certified physicians with training and experience treating the disease or condition in the practice area in question. This is rarely the case. Often a Mississippi doctor is on the phone with an out-of-state individual who has no experience or training in the Mississippi provider’s specialty. This is a misuse of time and resources for healthcare clinics. Insurance companies that are not properly equipped to handle these requests are not honoring the standard of healthcare that all our patients deserve and in some cases should rethink whether a prior authorization is even necessary.
The legislature has momentum to pass a strong prior authorization reform bill this session that will make insurers more transparent and accountable to the providers they utilize and the members they serve. Let’s stop the delay tactics and denials that are coming between Mississippi’s healthcare professionals and their patients.
Jay Underwood is president of Mississippi Independent Physician Practice Association.
