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MEDICAL PRACTICE
STRATEGIES & ISSUES

Prior Authorization

Hassles? By Jayesh B. Shah, MD

Every day it seems that regulations and red tape are increasing, and the hurdles to provide the best possible care
ratchet higher. We physicians in the trenches who are seeing patients are experiencing burnout as we try to do the
best for our patients. For example, I have to do at least two peer-to-peer reviews every week with insurance carriers
to make sure my patients get the care they deserve. Sometimes I worry about the peer-to-peer decision, as it is
difficult to grasp how a doctor reviewing a chart can make a better decision than the treating physician on the care
for their patient.

My typical day-to-day struggle is that insurance companies always physician in the same or similar specialty as the physician request-
expect an X-ray to be done before a CT scan or MRI. In my prac- ing treatment approval. This law definitely will help both physi-
tice, where I treat chronic wounds, an X-ray is a waste of time and cians and their patients.
money, since in most situations I am looking for an abscess or os-
teomyelitis. Chronic osteomyelitis changes take weeks or even Physicians should ask two basic questions before
months before they can be seen on an X-ray. but I have to do an starting a peer-to-peer conversation:
X-ray even when I do not need it. 1. Is the doctor conducting the peer-to-peer review from Texas?
I am not alone in my frustration with prior authorization. The 2. Is the doctor conducting the peer-to-peer review of the same
American Medical Association’s FixPriorAuth.org project launched specialty?
in July 2018. Since then, it has had 15 million impressions, 490,000+
engagements, 610+ patient and physician stories captured, 90,000+ Physicians must document in the patient’s chart their peer-to-peer
petitions signed, and 270,000+ messages sent to Congress. conversation if the physician conducting the review is from Texas
According to a recent AMA survey, 86% of American physicians and if he or she is making decisions on the management of the pa-
rated the prior authorization burden in their practices as “high” or tient. Is utilization review considered the practice of medicine? Can
“extremely high,” and 50% said that burden has “increased signifi- complaints against peer reviewers or insurance medical directors be
cantly” in the past five years. reported to the Texas Medical board?
but this is more than just an issue for the physicians. Our patients
suffer the most because of delayed care or no care. The same AMA Let us review current opinions by the Board
survey reported that 91% of physicians said that the prior authori- of Councilors at Texas Medical Association on
zation process has a somewhat or significantly negative impact on this subject.
their patients’ clinical outcomes; 75% said wading through the de- The board of Councilors serves as the ethical, policy-making
lays, denials, and appeals lead to patients abandoning their recom- body of the Texas Medical Association. Opinions of the board of
mended course of treatment; and 28% reported that the prior Councilors at TMA are based on the American Medical Associa-
authorization intrusion led to a serious adverse event for a patient tion’s Principles of Medical Ethics, current law, and the board of
under their care. Councilors' authority to investigate the general ethical conditions
The Texas Medical Association had a significant win in this leg- pertaining to the practice of medicine in Texas.
islative session with the passage of Senate bill 1742. This new law The current opinion of the TMA board of Councilors outlines
requires state-regulated health plans to post any prior authoriza- the role of insurance medical directors, medical necessity determi-
tion requirements on the Internet and opens the door for utiliza- nation and utilization reviewer’s roles and determines whether it is
tion reviews to be conducted earlier in the appeal process by a the practice of medicine:

22 San Antonio Medicine • January 2020