вЂњThere is a process that every company has in place that is based on evidence. вЂњSometimes the clinical evidence changes or there are changes to the formulary,вЂќ she says. вЂњThere are more and more things that need prior auths, which just puts me further behind schedule everyday.вЂќДЄparna Higgins, senior vice president, private market innovations, for AmericaвЂ™s Health Insurance Plans (AHIP), the industry trade group for healthcare payers, says that the goal of payer prior authorizations are to make sure patients are getting the proper care and most efficient care. He estimates his staff spends 20 hours a week on prior authorizations, which doesnвЂ™t include his additional time to get approvals. The appeal was approved eventually, but Kagan couldnвЂ™t get his time back.

вЂњJust one hospitalization would have blown all their savings,вЂќ says Kagan, who is a member of the Medical Economics editorial advisory board. The insurance company decided not to cover the drug any longer, requiring him to go through the appeal process-all for what amounted to a $30-per-month price difference. After putting her on a particular medication to treat the condition, she went 23 months without a hospital stay. Jeff Kagan, MD, a Newington, Connecticut-based internist, treated a patient with a chronic lung disease who had been hospitalized twice in a seven-month span. Related: Top 15 tips to improve the payer/physician relationship Physicians are baffled by payersвЂ™ requirements of prior authorizations for what they say are often routine, low-cost treatments or for drugs that have already proven effective for a particular patient for years, but suddenly need payer approval. Next: Tackling the growing numbers of prior authorizations HereвЂ™s why payers are taking these actions. вЂњAnd why are they issuing denials on meds that cost less than the copay?вЂќДЄccording to our survey, three areas stand out as the biggest frustrations for doctors: an increase in prior authorizations, an unwillingness by payers to negotiate reimbursement rates and an uptick in claim denials. вЂњIвЂ™m prescribing what I think is necessary and I have no financial incentive to do so,вЂќ says Belk. He points out that the bigger risk to the insurer is waiting too long for the scan, which could lead to severe consequences for the patient. Why does a nurse from an insurance company have to sign off on that? How is that about saving money?вЂќ says Belk. For example, ordering a CT scan for a possible case of diverticulitis requires a prior authorization, which appears to Belk as though the insurance company is trying to be the doctor.

What physicians consider necessary and practical care is often challenged by insurers who have no relationship with the patient. вЂњThey are trying to distract everyone with this image they are saving the healthcare system money when in reality, their revenue keeps going up and up.вЂќД«ottom line: independent physicians struggle with cash flow, hoping to get paid properly and in a timely manner while health industry juggernauts post multi-billion dollar profits. вЂњMost of our time is spent doing soul-crushing paperwork for no reason-it doesnвЂ™t help with anything,вЂќ says David Belk, MD, who runs a solo internal medicine practice in the San Francisco Bay area. They see insurers as вЂњplaying doctorвЂќ-making decisions on what treatments are proper-and ignoring their medical training and familiarity with the patient.

Doctors feel increasingly helpless and confused by what payers are doing and question how payersвЂ™ policies are saving money or improving care. Insurance companies score low (under five on a 10-point scale) in customer service, payment, patient information and communication with practices. Throw in a dose of government regulations that make doing business more complicated and you create an environment that can lead to frustration for physicians, as evidenced by the Medical Economics Payer Scorecard, which shows an overall low opinion of payers among physicians. With employers putting increasing pressure on insurers to freeze or lower prices, physicians often get caught in cost-reduction efforts from payers. The relationship between physicians and payers has always been turbulent, mainly because they serve two different masters: Doctors are trying to provide the best care possible while maximizing revenue to their practices most insurance companies are trying to provide the best care while increasing profit for shareholders and minimizing costs to employers. See more data from our 2017 Payer Scorecard here Ask any doctor what they think of payers and theyвЂ™ll likely say things that canвЂ™t be printed.

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