By Carmella Fernandez, M.D.
Associate Medical Director of Orthopedics, Cohere Health
I recently had a very pleasant 56-year-old gentleman in my office for evaluation of his hand. He was cleaning up his yard a few days before when he punctured himself with a fallen palm frond (a hazard unique to Florida) that he was concerned had gone under his skin. On evaluation, I could visualize a healed scab over his hand but I could not appreciate any palpable retained foreign body. He had no signs of infection and I prescribed him some antibiotics for prophylaxis. Considering the patient’s concerns and presentation, I ordered an MRI of his hand to evaluate for any retained vegetation/plant material. It was the best imaging for the situation in my judgement.
But I was notified by the patient and insurance company almost two weeks later that the MRI was not approved. The company told me that the patient required an X-ray of the hand prior to being approved to get the MRI, as was their standard policy for all advanced imaging. In this case, I knew an X-ray would not be effective since it would only demonstrate a foreign body which was radiopaque and, considering we were concerned about vegetation, it was unlikely to show anything. In addition, an X-ray would impose unnecessary radiation to the patient and more costs. I then requested and scheduled a peer-to-peer review – which itself could not be performed until the following week. Unfortunately, the situation escalated when I received a phone call that weekend from the local emergency department that my patient was in with a hand abscess and cellulitis up his forearm. I then urgently had to take him to the operating room to have his hand, wrist, and forearm opened and cleaned as the infection had spread from his palm up his forearm. Around the infected tissue was a large piece of palm frond which was likely the nidus for the infection.
My patient was fortunate. He was discharged and ultimately did very well with extensive formal occupational therapy. However, this case is just one dramatic example of how a delay in necessary evaluation can result in devastating clinical consequences, not to mention unnecessary medical expenses for the patient’s employer, and out of pocket expenses for the patient himself. Unfortunately, I am far from the only physician to have a story like this.
I kept the appointment for the peer-to-peer review as I felt it was important to relay to my colleague how the delay in authorizing my patient’s MRI potentially turned an elective case into an emergent one. My review was performed with an internal medicine physician. I explained my reasoning regarding the X-ray to the physician. She eventually stated that the MRI would be approved, at which point I had to tell her that the patient already had emergent surgery as he developed a severe infection.
We can take two lessons from this case regarding the prior authorization process. The first is the importance of minimizing turnaround time to prevent delays in diagnosis or evidence-supported treatment for a patient. Each day given to the prior authorization process is another day a complication could arise or another opportunity for the patient to discontinue their appropriate care journey altogether. When the situation worsens, the patient’s well-being is put at risk and further costs can be incurred by all parties involved.
The second issue is the need to communicate with a true peer in the same specialty to avoid potential delays. When physicians appeal, they deserve to engage with colleagues who have a clear grasp of the situation. As with the choice of imaging in this case, peers with a musculoskeletal background may better appreciate why the appealing doctor selected their course. This allows the peer physician to make a more helpful recommendation in the event an appeal is declined or else expedites the conversation around approval.
Prior authorization is a necessary part of care to ensure high quality decisions are being made in a consistent fashion, but that does not mean it has to involve as much time and frustration as it sometimes does in its current form. The ideal prior authorization process should prioritize patient care in a timely manner that gives high quality decisions. The reviewing nurse and physician team would then function as an extension of the provider’s care and be utilized as an additional set of eyes and ears to assure patient safety and efficiency.