Why preauthorization requests get rejected

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halbert
Veteran Member


Date Joined Dec 2014
Total Posts : 3103
   Posted 11/11/2017 1:21 PM (GMT -7)   
Again, back to the OP. In a way, it's a little bit heartening to learn that the "utilization review" people are actual MD's, not some barely trained paper pusher. That being said, as I and the others have pointed out, the reality is that preauthorizations get shut down mostly because of money. No surprise. And, as long as we whine about how much our insurance costs, then money is the only thing.

Sigh.
Age at Diagnosis: 56
RALP on 2/17/15, BJC St. Louis, Dr. Figenshau
58.5g, G3+4, 20%, 4 quadrants involved
PSA 3/10/15: 0.10
5/18/15: <.04
8/24/15: <.04
11/30/15: <.04
2/29/16: <0.04
8/30/16: <0.04
2/15/17: <0.006
8/22/17: <0.006
My Story: www.healingwell.com/community/default.aspx?f=35&m=3300024

Gemlin
Veteran Member


Date Joined Jul 2015
Total Posts : 603
   Posted 11/11/2017 1:48 PM (GMT -7)   
It doesn't need to be that way if the big pharma companies would sell at reasonable prices. For some of the expensive drugs the basic research has been done at universities and not by the pharmaceutical companies themselves. Some of the expensive drugs have actually been cheap to develop.
But the companies refuses to sell the drug at a reasonable price. When some countries (often in North America) accepts the high price then the company will not lower the price for other countries either.
Age at detection: 60
PSA 4.1 2014-02-25
Biopsy 2014-04-24, 4 of 10 cores positive, G: 3+4,4+3,4+3 EPE,4+3. PNI+
Bone scan negative
DaVinci 2014-08-31, nerve sparing right side
Prostate 35 g, 46x37x38 mm
Tumor dorsal PZ, SV-, 14 LN-, SM-, pT3a, G7 (4+3), EPE+ left side
PSA:
2014-10 <0.05
2015-03 <0.05
2015-09 <0.05
2016-03 <0.05
2016-09 <0.05
2017-09 <0.1

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8791
   Posted 11/11/2017 2:42 PM (GMT -7)   
It's not the patients that are to blame (OK, somewhat, for unnecessary procedures, tests, and drugs). But by far the biggest driver of medical spending in the US is from price increases. Hospitals and facilities and pharma/device mfrs are charging wildly inflated prices and raking in record profits. Step away from your personal anecdotes for a moment to look at the facts.

Between 1996 and 2013, US health care spending almost doubled in real dollars, increasing by almost a trillion dollars. Here's how that increase breaks down by changes in contributing factors:

US population size: +23%
Aging of population: +12%
Disease prevalence/incidence: -2%
Utilization of services: 0%
Price and intensity of services:+50%

"Services" includes such things as drugs, medical devices, diagnostics, imaging, therapies, doctor (ambulatory care) visits, emergency visits, nursing home stays, and in-patient services. "Service utilization" means such things as the number of visits and length of stays and number of prescriptions and number of bed-days. "Intensity of services" means spending more per visit, per prescription, or per bed-day including such things as additional services that are tacked on per incidence.

While service utilization cost increase netted 0, cost of inpatient stays dropped by 45% per stay, but the cost per bed-day more than made up for it. Ambulatory care visits and cost per visit were up too. ER and dental care spending increases were almost entirely due to price/intensity increases, and not the number of visits. Cost of increased use of pharmaceuticals increased by 67%. We're getting more drugs for each disease/visit and spending a lot more for each of those drugs.

The disease with the largest price increase was diabetes, which accounted for 11% of all price increases, and 2/3 of that was pharmaceutical price increases. Close behind were low back and neck pain, hypertension, hyperlipidemia, and depressive disorder price increases.

For prostate cancer, ambulatory care spending increases were driven by changing demographics. Inpatient care utilization was markedly lower, but that was more than offset by service price/intensity increases.

Factors Associated With Increases in US Health Care Spending, 1996-2013

So some of the increases are unavoidable (population and age-related). Some is avoidable - e.g.,exercise and nutrition to prevent diabetes. But half of it is due to price increases and increases in cost per visit.

In 2015, the US pharmaceutical industry posted record profits of $124 Billion - a return on R&D investment of 134%. Healthcare providers bring in about $1 Trillion in revenues per year in the US.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

halbert
Veteran Member


Date Joined Dec 2014
Total Posts : 3103
   Posted 11/11/2017 7:45 PM (GMT -7)   
Thanks TA. What is bizarre about the system is that it works in reverse to what a competitive market should do. In the rest of the world, increased use of a product lowers prices. In medicine, it's the opposite (there is a term for this in economic theory, but I don't remember it). The example I've seen is CT scans. 25 years ago, CT scans were primarily in big city major medical centers, and you had to travel to get one. (These were the machines that took a LONG time to get a scan done). And, the cost was high per use. No surprise, they were big, expensive to build and maintain, and took a large staff to operate. Nowadays, there are portable CT units on trucks that roam the countryside. One would think that cost per test would have gone down with the ubiqutiousness of it. Wrong.

Why is that? Because the market is inverted, for two reasons. One is that the person (insurance co's or gov't agencies) paying the bills isn't constrained--they can readily get more money from the customers by raising taxes/premiums. Two is that medicine isn't really a consumer product. People for the most part don't make medical care decisions like they make decisions to buy cars or toilet paper. If the medical person says, "your child has lymphoma", they don't sit down and say, "well, it's going to bankrupt me to do this, maybe the better choice is to let my child die". Not at all. They say, "cure my child!" Not only aren't we really capable or knowledgeable enough to truly weigh the costs and benefits of a particular treatment, we don't know what those costs are. Nobody at the hospital gives us a price list for the various choices and tells us to pick one from column A and two from column B.
Age at Diagnosis: 56
RALP on 2/17/15, BJC St. Louis, Dr. Figenshau
58.5g, G3+4, 20%, 4 quadrants involved
PSA 3/10/15: 0.10
5/18/15: <.04
8/24/15: <.04
11/30/15: <.04
2/29/16: <0.04
8/30/16: <0.04
2/15/17: <0.006
8/22/17: <0.006
My Story: www.healingwell.com/community/default.aspx?f=35&m=3300024

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8791
   Posted 11/11/2017 10:12 PM (GMT -7)   
Halbert,

I agree. Economic theory depends on rational markets, and the healthcare market is anything but rational. Competition is supposed to drive prices down, but only if the consumer knows the prices and can shop for lower prices. Hospitals make up prices at random as far as I can tell. Big Pharma seems to compete to see who can charge the most outrageous price and get away with it. Patients in the US subsidize lower drug prices for the rest of the world.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

halbert
Veteran Member


Date Joined Dec 2014
Total Posts : 3103
   Posted 11/12/2017 5:48 AM (GMT -7)   
Medical pricing is a scandal of the highest order. Some investigative reporting has been done, and it shows that medical "list pricing" is actually set by the insurance companies with the understanding that the doctors and facilities will accept much less--which makes it possible for the company to advertise that they are saving you 50% (or whatever) off your bill with the "negotiated amount". Which isn't negotiated at all. The insurers go to the doctors and TELL them where to set their prices.

In most businesses, capital expenditures are depreciated over time, and the prices are set to include the depreciation. So, for simple example, a basic X-ray machine at your doctor's office might cost him $50K to install. In theory, it should be depreciated over 20 years, and the incremental cost per X-ray based on 20 years, 250 office days per year, and 25 uses per day is $2.50 per x-ray. Let's say, if you're figuring in wages for everyone that is involved with that X-ray, that the total COST of the X-ray is $50. And yet they bill you what, $1000?

It's monopolistic behavior at it's worst. Health care on a large scale is the very definition of a natural monopoly, and the medical professionals are caught in the web just as badly as we are.
Age at Diagnosis: 56
RALP on 2/17/15, BJC St. Louis, Dr. Figenshau
58.5g, G3+4, 20%, 4 quadrants involved
PSA 3/10/15: 0.10
5/18/15: <.04
8/24/15: <.04
11/30/15: <.04
2/29/16: <0.04
8/30/16: <0.04
2/15/17: <0.006
8/22/17: <0.006
My Story: www.healingwell.com/community/default.aspx?f=35&m=3300024

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8791
   Posted 11/12/2017 10:54 AM (GMT -7)   
Here's my latest anecdote-- Two years ago I fell and needed 15 stitches for a cut on my forehead at the ER. They billed my insurance company $8,000, and my insurance agreed to pay them $1,500. They came after me for the rest. I told them no way and asked for an itemized breakdown. It included a $5,000 suture kit. $5,000 for some sterilized threaded needles! I told them to stick it. They reduced subsequent bills randomly - $50, $500, $10, $250 and have turned it over to a collection agency who calls and sends more random bills. It dropped my credit score by 100 points. This is from one of the largest hospitals in LA that takes in $2.4 billion in annual revenue.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

Pratoman
Veteran Member


Date Joined Nov 2012
Total Posts : 4896
   Posted 11/12/2017 11:38 AM (GMT -7)   
mattamx said...
I understand the frustration that people can feel when they believe other people are gaming the system, and there are always going to be people who cheat any system. My opinion is that the vast majority of people getting entitlements need them. I work as a peer in mental health and it touches me that most of them say they wish they could trade their disability for the ability to work


I agree with this, it's not fair to generalize about people receiving these entitlements. (Not saying anyone here is doing so). I think most people without insurance simply can't afford it.

I was in the emergency room a few weeks ago, after they figured out what was wrong with me, ER doc comes in and says, "what's your insurance" to which I replied Medicare. Follow up question "do you hve supplemental?, I say yes. He responds, ok, we're going to admit you. shakehead

I have a good friend with a blood disorder that multiple doctors have not been able to figure out and it is a huge detriment to his QOL. He finally finds a Dr proactive enough to do ore than order more blood tests, she wants a PET scan. Insurance rejfuses to approve it.

I don't know how this gets fixed. There's a problem with every solution. But it sure is broken.

PDL17
Regular Member


Date Joined Oct 2011
Total Posts : 462
   Posted 11/12/2017 12:31 PM (GMT -7)   
My wife and I are retired and have a bronze plan of insurance that has a deductible of 6000 for each of us. Almost everything we purchase is out of pocket. This has caused us to ask the price for everything medical. It is amazing how much people will decrease their prices once they know insurance is not involved. However, it has also caused us to only get what is absolutely necessary. I currently have lower back spasms. In the past, I would see either a chiropractor or physical therapist in conjunction with an orthopedic physician usually referred to me from my primary care physician. X-rays, MRI's, and new prescriptions would always follow. I, like many had no reservation in using these resources when someone else was paying the bills. The diagnostic tests never revealed anything, the drugs only made me tired, the chiropractors always did things that make me scratch my head, and the physical therapists gave me exercises. I now can't afford any of these services so I have pulled out the old exercises and can not tell any difference in rate of recovery. Unfortunately, we are spoiled by a corrupt system. I agree with JT on the need for future rationing. We have to start educating each other regarding what is necessary and what isn't. Physicians still get paid to do procedures on 90 year old patients and run excessive tests that yield no benefit. We have to start getting educated and not be persuaded by political parties running adds on pushing grandma off of cliffs and death panals anytime someone brings up health reform. Both political parties are equally guilty of this so I hope no one gets offended.

Finally, as a pharmacist, I can not believe how many patients are now on 10 medications or more (often more than 20). There are a multitude of over prescribed drugs that do very little towards extending quality or quantity of life.



Paul
Gleason 3+4; 5/16 positive cores; average volume 30%; PSA prior to tx 4.8
TX-IMRT + brachytherapy; IMRT Nov. 2011; Brachytherapy Feb. 2012
PSA April 2012--3.6
PSA May 2012--2.5
PSA Aug 2012--2.2
PSA Nov 2012--2.9
PSA Feb 2013--2.8
PSA May 2013--2.1
PSA Aug 2013--2.3
PSA Nov 2013--2.5
PSA May 2014--1.1
PSA Dec 2014--0.8
PSA Jun 2015--0.5
PSA Jan. 2016--0.4
PSA Aug. 2016--0.4
PSA Mar. 2017--0.3

Gemlin
Veteran Member


Date Joined Jul 2015
Total Posts : 603
   Posted 11/12/2017 3:36 PM (GMT -7)   
Tall Allen said...
Here's my latest anecdote-- Two years ago I fell and needed 15 stitches for a cut on my forehead at the ER. They billed my insurance company $8,000, and my insurance agreed to pay them $1,500. They came after me for the rest. I told them no way and asked for an itemized breakdown. It included a $5,000 suture kit. $5,000 for some sterilized threaded needles! I told them to stick it. They reduced subsequent bills randomly - $50, $500, $10, $250 and have turned it over to a collection agency who calls and sends more random bills. It dropped my credit score by 100 points. This is from one of the largest hospitals in LA that takes in $2.4 billion in annual revenue.


Allen, A similar accident happened to me, a fell and needed 10 stitches on my chin at the nearest ER. Since we have public healthcare in my country they charge you only $40 per visit at an ER. I have a private accident insurance, so the insurance company payed me the $40 back plus $1000 as compensation for the aches. How different it could be.

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8791
   Posted 11/12/2017 3:45 PM (GMT -7)   
I also had a $250 co-pay. Does Sweden allow Americans to immigrate?
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

JNF
Veteran Member


Date Joined Dec 2010
Total Posts : 3388
   Posted 11/12/2017 5:33 PM (GMT -7)   
Hal

Your reference to depreciating a medical machine over 20 years doesn’t fit. Technology is much faster than that. The LINACS I was treated with seven years ago were state of the art but are gone today. That is another cost problem as we must pay the current cost of technology not the depreciated cost.

TA

Getting in to Sweden is easy. Getting on their benefits is another issue as it should be. I suggest you file a very significant suit against your provider They can not charge you more than they negotiate with insurance. Also go to your local consumer reporter as they would love to have this example.
PSA 59 on 8-26-2010 age 60. Biopsy 9-8-2010 12/12 positive, 20-80% involved, PNI in 3 cores, G 3+3,3+4,and 4+3=G7, T2b.
Eligard and Jalyn started on 10-7-2010. IMRT to prostate and lymph nodes started on 11-8-2010, HDR Brachytherapy December 6 and 13, 2010.
PSA < .1 since February 2011. Located in Cumming Georgia north of Atlanta

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8791
   Posted 11/12/2017 5:56 PM (GMT -7)   
While I was bleeding, they had me sign a contract saying I would cover the cost if my insurer refused. It probably wouldn't hold up in court (signed under duress). They also made me wait for 6 hours in the ER so that they had to debride the wound before stitching it up, causing a greater scar than there would have been.

They tried to get me to agree to a whole slew of diagnostics, which I refused. The nurse was affronted that I wouldn't let her take blood or send me for a CT scan (service intensity) because it was part of their standard operating procedures. But the doctor actually listened to me, and agreed with me. If he hadn't, the bill for a few stitches would easily have been over $10,000.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

Tim G
Veteran Member


Date Joined Jul 2006
Total Posts : 2226
   Posted 11/12/2017 6:06 PM (GMT -7)   
This has been an excellent and thoughtful discussion. My personal observation is that there is a lot of robbing-Peter-to-pay-Paul going on. Here is a simple example from my 40 years as a medical lab tech.

The government under Medicare pays $3 for the task of collecting a blood sample, which includes the phlebotomist's salary and the cost of the blood collection equipment. Needle cost is about 30 cents for a regular needle, $1.50 for a butterfly needle, and about 50 cents per blood collection tube. You've chewed up your reimbursement with the cost of equipment without considering the phlebotomist, whose dismal pay helps contribute to the hospital's profit margin.

Insurance companies try to make their reimbursement for healthcare match the government's. Healthcare organizations try to increase profits in other ways, hence the stratospherically high bills for other equipment and procedures.

This is a simple example, which can like love, become very complicated, but it serves to illustrate the Bedlam-like insanity that exists in the mad world of healthcare, which includes dentistry as well.

Break60
Veteran Member


Date Joined Jun 2013
Total Posts : 1760
   Posted 11/13/2017 6:47 PM (GMT -7)   
This is an amazing thread; however I have found no problem so far getting Medicare approval for any of the numerous procedures I’ve had since turning 65:
Knee surgery meniscus repair
Shoulder surgery rotator cuff
Total Shoulder replacement
Radical prostatectomy
Numerous scans
Radiation to prostate bed 38 sessions
Radiation to lymph nodes 50 sessions
Radiation to femur 3 sessions sbrt
Colonoscopies
Radio frequency ablation to rectum
Numerous Lupron shots
Xgeva shots

And I haven’t paid anything except Medicare and Medicare supplement plan premiums and drug copays .
My experience is that senior citizens have great medical insurance. Maybe too great?!

Bob
DOB January 1944
8/’12 PSA 2.7; 5/’13, PSA 6.6 (actually double due to finasteride)
7/’13 Bx GS 4+5=9 , 2 of 6 cores, 10%, 40%; stage Pt1c
9/’13 ORRP, pathology GS 4+5=9, EPE and margin+ at base (4mm, GS7), BLSVIs+, 10 lymph nodes resected (clear); stage upgraded to Pt3bN0M0
11/’13 - 5/’14, PSA 0.1 to 0.3
6/’14 SRT by IMRT/IGRT (68.2 grays/38 Fx) to prostate bed, ADT (6 months Lupron)
9/’14 - 8/’15: PSA: <.1, to 1.2
9/’15 MRI, CT-PET finds two iliac lymph nodes suspicious for PCa; started 13 months of ADT3 (Lupron, bicalutamide, dutasteride) plus plus metformin, cabergoline, estradiol patches, prolia , vitamin D3, calcium. IMRT/DART (75 grays/50 Fx) to pelvic lymph nodes. Stopped ADT3 11/’16.
11/’15 - 5/’17: PSA .03 to 2.3.
2/’17: Rx finasteride added
5/’17: F-18 Fluciclovine (axumin) PET/CT scan finds 9 mm femur met. Restart ADT3; start monthly Xgeva, stopped finasteride.
6/’17 SBRT via IMRT (27 grays/3 Fx) to femur met.
6/’17 - 10/’17 PSA .3 to <.1
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