Oncologists Face Nightmares Every Day With Prior Authorization

Maen Hussein, MD


August 04, 2021

Editor's note: Prior authorization has been flagged as the biggest payer-related cause of stress for US oncologists. In one survey, 75% said prior authorization was their biggest burden, followed by coverage denials and appeals (62%). Another survey found that practices spent on average 16.4 hours a week dealing with prior authorizations.

In the 16 years since I went into practice as a medical oncologist, the issue of prior authorization has become a nightmare.

Dr Maen Hussein

Around 5% of my emails every day are from insurance companies denying my patients the treatments I have recommended. A part of every day is spent worrying about how I'm going to cover my patients' therapy and what I need to order to make sure it doesn't get delayed.

Many doctors are retiring because they don't want to deal with this anymore. There are many times that I have thought about quitting for this reason. A partner of mine had a heart attack last year. He's a few years older than I am ― in his mid-50s ― and that scared me. I actually had a CT angiogram just to make sure. They told me my heart is fine, but I worry because of all these frustrations every day. And I'm not alone. For every doctor I work with, it's the same story, and it's just ridiculous.

For example, I had a patient with a huge breast mass. My nurse got me the prior authorization for an emergency biopsy. I got back the results for estrogen and progesterone receptor status, but not the HER2-neu results because that test required another authorization.

Authorization shouldn't be required for every single step. I understand if maybe you need to get an authorization to do something outside the standard of care or something that is unique or unheard of, but HER2-neu biopsy is standard of care and should not require additional authorization.

And the sad part is, that patient turned out to be HER2-neu positive. She lost 4 weeks just waiting for an authorization of a test that should be a no-brainer.

We cannot even do a blood count in our office before getting authorization from some insurances. This is a very important test when we give chemotherapy, and it's very cheap.

And then another nightmare is if you want to give a patient growth factors when you see their blood count is going down. Sometimes the insurance company will say, "When they get neutropenic fever, we'll allow it with the next cycle." Why do I have to wait until the patient develops such a problem to start with a treatment that could avoid it? They may end up in the hospital.

I think I'm one of the more conservative doctors; I try to do everything scientifically and only order a test or a treatment if it's indicated. But sometimes this guidance costs more money. For example, an insurance company may say to order a CT scan first and if you don't find your answer, then get a PET scan.

So I order a CT scan, knowing it's not going to help, and then I tell them, "Now I need a PET scan." That's another week delay and an extra cost that I don't want the system to incur.

I've even had some issues with lung screening scans for smokers. This screening has reduced mortality by 20%; it should be a no-brainer to encourage smokers to do it because many of them may not even need chemotherapy if you find early-stage lung cancer. And the screening is not expensive, you can do it for $90 to $100. So why do we have to get authorization for that?

Sometimes I push back and request a "peer-to-peer," where you challenge the decision of the insurance company and speak to one of their doctors. Out of 10 doctors, maybe three or four will do the peer-to-peer. The rest will give up because it's so frustrating.

In one case, I wanted to modify a standard regimen and give only two out of three drugs because I thought the third would be too toxic. But the insurance company wouldn't approve the regimen because the guidelines say you have to give three drugs.

Guidelines are guidance, they should not dictate how you treat an individual patient ― there should be some allowance in there for a doctor's discretion. If not, why do we even need doctors? We could just follow treatment regimens dictated by computers. They have to allow me to personalize the care that my patient deserves and make changes so that the treatment can be tolerated.

But then, I get that one patient whom I feel I really helped and I realize, "Okay, I can help more people."

I had this one patient, a young, 40-year-old nurse with breast cancer ― also HER2-neu positive. She'd had her surgery and finished her adjuvant chemotherapy. One of the things that you do as standard of care, after a year of trastuzumab, is you start them on neratinib. There are studies that show it improves progression-free survival if you give them an extra year of this drug as an adjuvant.

I prescribed the neratinib, but the insurance company denied it because the patient "did not have positive lymph nodes and was not considered high risk." I told them, "That's BS, that's not what the indication is for." I asked for a peer-to-peer and they said the policy did not allow for peer-to-peer. So, I made a big fuss about it. We appealed, and I finally spoke to a pharmacist who worked for the insurance company. I told him, "Why did you guys deny this? It's standard of care." He said, "Oh, I agree with you, this will be approved. And actually, we're going to change the policy now."

When that pharmacist told me they were going to change the policy, it was like someone gave me one million dollars. Because, you know what? I didn't just help my patient; now other patients will also get it. The hope is that if you keep fighting for something, they will change it.

I think every doctor wants to do the best for their patients. It's not like they don't want to, but really, I am fortunate that I have the means to do it. We're a big practice and have dedicated staff who can help.

If you're a small practice, it's almost impossible to deal with this. I have two nurse practitioners, and a lot of their work is filling out paperwork for insurance companies.

We had a colleague, a solo practitioner, who would send us his patients with complicated therapies, because he couldn't afford the time or the effort or the risk of not getting reimbursed. His practice could have paid out $100,000 for drugs and not get a reimbursement for a few months.

Even when an insurance company does give the preauthorization, there's always this disclaimer that it doesn't guarantee payment. If they find in the future that your patient didn't meet the criteria, they can still deny payment.

If the insurers refuse coverage, we really work hard at getting patients free drugs, and most of the time, we manage to do that. We either look to charitable organizations, like the Leukemia and Lymphoma Society, or we look for rare disease societies or we go to the pharmaceutical company.

For really expensive drugs, pharmaceutical companies have a program where you can enroll the patient and they can help copay or even cover the drug. For less expensive drugs, it might not be a big problem, but for a drug that can cost $18,000 to $20,000 a month, that's a big risk to take.

It's confusing for patients, too. They get angry and frustrated, and that's not good for their treatment, because attitude and psychology are very important. Sometimes they yell at us because they think it's our fault. I encourage them to call their insurance company themselves, and some of them do.

I don't do it with every patient, but there are some more educated patients who are advocates, and if their condition is stable, I do encourage them to call their senators or congressmen or women to complain.

I don't mind treating complicated patients. I don't want to say I enjoy it, but I like challenges. That's my field, that's medicine, that's what I'm supposed to do. But it's really sad and frustrating that, when you want to treat a patient, you have first to look at their insurance to see how much care you can actually give them.

Maen Hussein, MD, is physician director of finance at Florida Cancer Specialists and Research Institute, Fort Myers, Florida. He is also a board member of the Florida Cancer Specialists Foundation and sits on the board of directors for the Florida Society of Clinical Oncology.

This article is based on comments from Dr Hussein as told to freelance medical journalist Kate Johnson, who is a regular contributor to Medscape Oncology.

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